Health disparities have historically impacted multiple populations throughout the U.S. When it comes to health and access to healthcare, consider the plight of Native Americans, undocumented immigrants, people experiencing homelessness and the chronically mentally ill, and rural communities in places like Appalachia, and we see a picture of what’s broken. The undeniable disservice that continues to millions of the most vulnerable is inexcusable, yet this legacy is slow to overcome.
In terms of Black communities and people of color, the disservice is centuries-old. To this day, the legacies of structural racism live on in health disparities that would have no place in 21st-century America if we had already learned our lessons and lived up to the potential outlined in our country’s founding documents.
Nonetheless, disproportionately negative statistics don’t lie. We know beyond the shadow of a doubt that Black Americans have received short shrift in the realms of health and healthcare since the first days of the American colonies, and the work to undo these wrongs is daunting and ongoing.
Distrust, Disparities, and Deceit
The Kaiser Family Foundation website states, “While Black people have made great contributions and achievements in the United States, they continue to face many health and health care disparities that adversely impact their overall health and well-being. These disparities have been exacerbated by the uneven impacts of the COVID pandemic, ongoing racism and discrimination, and police violence against and killings of Black people. Moreover, the long history of inequitable health outcomes among Black people reflects the abuses faced during slavery, segregation, mass incarceration, and their persistent legacies.’
Kaiser’s statistics point out that Black people face more significant financial obstacles to receiving appropriate healthcare and have a higher uninsured rate than white people. And with higher rates of poverty and food insecurity, it’s clear that many factors contribute to this calculus.
“The growing gap of health disparities within the American healthcare system is resulting in the unnecessary deaths of people of color and the continued mistrust of the healthcare system,” states Jasmyn Moore, MBA, BSN, RN, co-host of the Distrust and Disparities podcast.
“If you take a deep look into most health disparities that plague communities of color,” Ms. Moore continues, “you will see that the root cause is systemic racism. The medical field was built off experimenting on Black bodies.” In this statement, Ms. Moore is referring to a legacy exemplified by the Tuskegee experiments, where Black men were misled by researchers to believe that their syphilis was being treated, but in actuality, the course of the disease could be observed by scientists from the U.S. Public Health Service.
“We have all heard the negative statistics surrounding the health of Black, Indigenous, and people of color,” Moore states. “Black mothers are three times more likely to die during childbirth. Black infant mortality is twice as high compared to white babies. African Americans are more than twice as likely to die from cancer.”
Disturbing statistics are nothing new in the world of racial minorities in the United States. Moore comments that “the life expectancy gap between marginalized ethnic groups continues to widen despite health advancements. We are constantly bombarded with those negative and disheartening statistics. The blame is often placed on individuals and families versus a health care system that was not designed to promote and protect our health and livelihood.”
Moore concludes with the following food for thought: “Behind each of those statistics, racism plays a big factor that is often ignored. A report released by the National Academy of Medicine in 2003 pointed out how, in America, race is a determinant of health quality. Their study detailed how Black people and other ethnic minorities receive lower quality of health care than white people even when age, income, insurance status, and severity of conditions are comparable.”
Heightening the Focus
“The COVID-19 pandemic and nationwide racial justice movement over the past several years have heightened the focus on health disparities and their underlying causes and contributed to the increased prioritization of health equity,” states the Kaiser Family Foundation. “These disparities are not new and reflect longstanding structural and systemic inequities rooted in racism and discrimination.”
Aggressively addressing disparities at their root — including police violence against Black citizens, maternal-infant mortality, discriminatory housing policies, income inequality, the impact of climate change on vulnerable populations, and access to care — can lead to us cooperatively working together to find multifaceted and forward-looking solutions.
As the Kaiser Foundation pointed out, these disparities are nothing new; thus, dismantling the structural and societal issues that cause them is an uphill battle. That said, many individuals and organizations have set their sights on these issues, and the 21st-century racial justice movement is an intrinsic part of that process.
Those of us in the healthcare industry must maintain awareness, examine our own biases, and demand that our workplaces do their part in decreasing disparities impacting the populations of color that we serve. We carry that responsibility; stepping up and speaking out is our individual and collective moral obligation.
Nursing strives to exceed the boundaries when it comes to providing patient care in the United States, and nursing leaders have long understood the importance of diversity in the workplace to obtain quality outcomes for their patients.
Over the last decade, the American Association of Colleges of Nursing (AACN) has dedicated efforts to diversify the workforce. The aim is to have adequate representation from all groups—including men and individuals from the African American, Alaskan Native, Asian, Hispanic, Native American, Native Hawaiian, and those of other backgrounds.
Improving nurse workforce diversity will help decrease health disparities and increase health equity so all people of all groups can be as healthy as possible. Because different populations often present symptoms dissimilarly or are predisposed to distinct conditions, it’s important for nursing schools and staff to gain a wider perspective on the patients they serve. In parallel, when nursing staff mirrors the population they serve, it’s common for patients to feel more trusting and comfortable discussing their personal concerns and symptoms.
The National Council of State Boards of Nursing (NCSBN) and The Forum of State Nursing Workforce Centers were surveyed in 2017 to look at the cultural makeup of the nursing pool. Registered Nurses (RN) from minority backgrounds represented 19.2% of the workforce.
The survey identified the RN ethnic backgrounds comprised of 80.8% white/Caucasian; 7.5% Asian; 6.2% African American; 5.3% Hispanic; 0.4% Native American/Alaskan Native; 0.5% Native Hawaiian/Pacific Islander; 1.7% Two or more races; and 2.9% other nurses. Of the total nursing workforce, men accounted for 9.9% of the workforce, up from 1.1% from 2015.
Elmhurst University, located just outside of Chicago, is committed to successfully recruiting and retaining their nursing students to meet the growing need in their communities. Elmhurst’s mission is to prepare nurses for professional practice and exceed leadership roles to meet the needs of a diverse society.
If you are looking for a new career path in high demand, a degree in nursing can launch you into a highly respected, satisfying, and financially stable profession. Elmhurst University understands the importance of providing high-quality nursing degrees in a timeframe that matches the workforce demand.
Find the Right Program for You
Elmhurst University offers a distance accelerated BSN nursing program for those who are ready to begin their nursing career today. Students complete all course requirements in less than 2 years. An online distance learning structure allows those living in remote areas to gain access to a high-quality nursing education. Furthermore, there are just two on-campus visits during the program, limiting the number of travel disruptions to students.
Elmhurst University nursing students.
The 16-month fast-track program prepares students to sit for the National Council Licensure Examination for Registered Nurses (NCLEX-RN) exam. Elmhurst University is consistently above the national and state scoring averages on the NCLEX exam. In 2020, 90% of their BSN students passed the exam.
Elmhurst University’s application process is easy to access online. Apply today and take the first step to a rewarding career.
Last December, the FDA reported on both the Pfizer-BioNTech and Moderna Covid-19 vaccine and the respective race and ethnicity of their research participants in the Phases 2 and 3 research trials. The Pfizer trial included ages 16 or older and the Moderna trial included those 18 and older. Of 285 million in the United States population, over 40 thousand participated in the Pfizer trials and over 27 thousand in the Moderna trial. When looking at the combined totals of subjects compared to the general population, whites were found to be over represented. Whereas 73.6% of the U.S. population are white, 79.4% to 81.9% of the subjects reported their race as white. American Indian/Alaska Native and Native Hawaiian or Other Pacific Islanders had the exact percentage of research participants to those of the U.S. population; 0.8% and 0.2%, respectively. The second largest contrast in proportion of participants to the U.S. population was seen in comparing those of Asian race. Only 9.7-9.8% of research subjects reported themselves as Asian, whereas the total U.S. population percentage is 5.9%. The biggest discrepancy can be seen in research participants who reported their race as Black. Only 9.7-9.8% of research subjects were Black, whereas Blacks make up 12.3% the current total U.S. population. Regarding ethnicity, 17.6% of the U.S. population reports themselves as being Hispanic and 20-26% of participants identified themselves of Hispanic ethnicity. However, 82.4% of Americans report themselves as non-Hispanic and 73.2% to 79.1% of research subjects identified themselves as that ethnicity.
Despite these Covid-19 vaccine trials demonstrating greater diversity than previous trials of other pharmaceuticals, these statistics still represent a disparity in the representation of people of color as research participants in a vaccine designed to boost the immunity of a virus that is disproportionately affecting people of color in the United States.
The good news is that despite this disparity in the diversity of representation in the clinical trials, the findings did show that the safety and efficiency of the Pfizer-BioNTech and Moderna vaccines were similar across groups despite race. The question many pose in reaction to such statistics is why minorities are underrepresented in clinical trials. The main four reasons include: barriers to access, lack of information, and historical and continuous racism and discrimination. Barriers to access come in the form of few clinical trials being offered through under-resourced hospital systems that minorities use for health care. Also, minorities are less likely to have eligibility to participate in such trials due to having co-morbid conditions or not having health insurance. These attributes can exclude them from participation in such research studies.
Other challenges to access may be their limited or lack of transportation resources, being unable to request off of work, caregiving schedules, or not having access to technologies for monitoring during a research study. Some research studies have reported that physicians are less likely to offer clinical trial participation to minority patients. Enrollment efforts of research studies often may not reach the minority population if they are not culturally sensitive to address language or health literacy barriers. The history of medicine in the United States also has seen the abuse and mistreatment of minorities such as the Tuskegee syphilis experiment. As a result of such abuse and ongoing racism and discrimination, minorities are less willing to participate in clinical trials.
The racial and ethnic diversity of clinical trials in the further development of Covid-19 vaccines is imperative. This pandemic has impacted those of Black adults and minorities the most, so more trials should effectively recruit and maintain the participation of minorities. Minorities already historically have had lower vaccination rates and express more concerns about receiving the Covid-19 vaccine and perhaps their concerns are valid based on the data presented in this essay. Therefore, it is important that Covid-19 vaccine researchers ensure the safety and efficiency of the vaccine across all of the United States to increase the trust and confidence of minorities that they should get the vaccine.
The recent announcement by Pfizer of a potentially effective COVID-19 vaccine has led to great excitement, even though some nurses express misgivings about the speed of COVID-19 vaccine development. This vaccine development would not be possible, of course, without the participation of many thousands of volunteers in clinical trials. Unfortunately, minority participation in these COVID-19 trials has lagged.
“As we strive to overcome the social and structural causes of health care disparities, we must recognize the underrepresentation of minority groups in COVID-19 clinical trials,” notes a column in the August 27, 2020 issue of The New England Journal of Medicine.
A major reason for this underrepresentation involves “distrust of researchers, healthcare in general when it comes to communities of color,” notes Ernest J. Grant, PhD, RN, FAAN, president of the American Nurses Association (ANA). That distrust, he notes, harkens back to such appalling experiences as the “Tuskegee Study of Untreated Syphilis in the Negro Male,” where hundreds of Black men were recruited to study syphilis without treatment.
“Trusting Relationship”
Dr. Grant suggests a number of ways to address the underrepresentation of minorities in COVID-19 clinical trials. One is to provide thorough education as people are being recruited into a trial. Another involves the recruiter. “There tends to be more of a trusting relationship if they see that it is a researcher that perhaps resembles them, or is from their culture,” according to Dr. Grant.
Another tactic involves recruiting a “community influencer or someone like a pastor or a community leader or doctor or nurse within the community that people respect.” Those influencers, he notes, can help dispel myths and address uncertainties potential minority participants may have.
Once a vaccine is available, minorities are at special need of receiving the treatment, especially because minorities are at greater risk of not surviving or having a more difficult time with the disease. The virus, notes Dr. Grant, tends to proliferate more when there are comorbidities that tend to be more prominent in black and brown individuals, such as hypertension and diabetes. “When a vaccine does come along, it would prove to be more beneficial and reduce their chances of succumbing to this virus,” he says.
ANA President as Study Participant
Practicing what he preaches, Dr. Grant is currently participating in a COVID-19 vaccine phase III clinical trial at the University of North Carolina. He will be followed for two years.
One reason for his participation, he says, is the knowledge that more minority participants are needed. Another is that as a leader of the nation’s nurses, “it’s my way of trying to give back to them, knowing that they will be some of the first individuals to take the vaccine once it is approved.”
Dr. Grant ask nurses to consider volunteering for a clinical trial, and then once a vaccine has been approved, to “educate themselves so that they can educate the public.” Nurses also need to be at the table, he notes, when decisions are being made about such things as vaccine distribution. Nurses, he says, “obviously play a very critical role in that process.”
The first quarter of 2020 has revealed, to many, the depth of the racial problem in American society. First, COVID-19, which has disproportionately impacted communities of color, revealed the inequities in the American health care and economic system. Then, the killings of three African Americans, Ahmaud Arbery, Breonna Taylor, and George Floyd, by white men, including police officers in two of the cases, restarted a conversation on racial violence and police brutality in America. All of this has led to a national discussion on the health of the American republic.
To provide some illumination on this important topic, we interviewed Dr. Stacie Craft DeFreitas, who has a PhD in Clinical Psychology from Duke University. Her interest in race, ethnicity, and academic achievement was sparked in high school when she participated in Kaleidoscope, a math and science enrichment program for African American students housed on the campus of Wake Forest University. Her work, African American Psychology, is a highly relevant work that covers many of the issues raised by the recent events in America. She is currently an Associate Professor of Psychology and the Assistant Chair of the Social Sciences department at the University of Houston-Downtown.
DeFreitas, what is your reading of the origins and purpose of the current Black Lives Matter movement and how do you place it in the historical context of black civic action in the United States?
The current Black Lives Matter movement stems from the murder of Trayvon Martin in 2012 when women of color began using the hashtag to bring awareness to such acts against people of color. Nearly 10 years later, the movement is still striving to protect black and brown people from such state sanctioned murder. Black Lives Matter is one of the larger current movements pushing the United States towards the ideals that are penned in the Declaration of Independence and Constitution. BLM is forging a place in history as an agent for change.
What motivated you to write the book African American Psychology and how is it relevant for understanding race in America today?
It seemed to me that there were not enough messages about the strengths of African Americans out there in the world. There was so much negative media and I wanted to realistically counter that. I wanted to tell more of the story of the African American community by focusing on the historical elements that have led to the current psychological state of African Americans as well as look at how the strengths can be used to help the community prosper. There are so many people that really need to read this book so that they can begin to get a better understanding of African Americans in this country. Many people assume that they know about Black people because of the media that they ingest, TV, movies, news, and music. Many people do not know that they often get a stereotypical view of African Americans and only see the lives of a small subset. African Americans are heterogeneous. There is so much diversity within this group that is often ignored. This book also helps to bring some of that out. It will help readers to understand that African Americans are strong and resilient people who have survived so much and often come out of the other side better off. But it will also help readers to understand that they are battling so much and that we should marvel in all of the progress that has been made despite the plethora of barriers. Perhaps readers will love and admire the African American community as I do once they have a better understanding of their lives, or at the very least reevaluate their own biases and stereotypes.
What was the most surprising thing you learned, as an African American woman and psychologist, about the psychology of African Americans during your research for the book?
This may not be surprising to others, but I learned more about all of the ways that the United States has worked to keep African Americans from prospering. I knew about some of it, but got a much better understanding of the events in Rosewood, lynchings, the Tulsa bombings, redlining, and other ways that citizens and businesses worked to keep African Americans from prospering. There was so much, I chose not to include much of it in the text as I assumed someone would say that I was being anti-American and would therefore discount the book. It amazes me that we sweep these things under the rug and imagine that since slavery, or at least since the Civil Rights Movement, the U.S. has only tried to support African Americans. That is clearly not true and continues to be untrue today. Doing nothing is often the same as doing harm.
Can you discuss the nature of structural racism in the U.S. and some of the ways it impacts the mental and physical health of African Americans?
Structural racism is weaved into the fabric of the United States. It is inherent in its capitalist ideologies, laws, history, and culture. Racism impacts the mental and physical health of African Americans in so many ways. One very important way is through racism’s impact on where and how people live. African Americans are much more likely to live in impoverished neighborhoods as a result of the history of racism in this country and the current laws that do not protect or support them fully. Unfortunately, I cannot go into all of the racist practices that work to push Black people into segregated and often lower income neighborhoods, but there are many, and they continue to be practiced today. One example is crime free housing ordinances which allow landlords to evict or deny housing for any person who is suspected of a crime which effectively works to deny housing to people of color as a result of heightened, unjustified police surveillance among people of color, especially Black men. The neighborhood that one lives in impacts the schools that they attend, the quality of the restaurants that they are near, whether they live in a food desert, the recreational space available to them, and other factors that all impact mental and physical health.
Further, racism has created a system of mistrust between Black patients and their often non-Black health care providers. Black patients often do not trust these health care providers to really have their best interest at heart as result of a history of mistreatment. Because of this mistrust, they often avoid going to the doctor for as long as they can and they are less comfortable sharing all of their symptoms when they finally do go to the doctor. Doctors in turn do not trust their Black patients to carry out their prescribed orders and they often discount their experiences. This cycle leads to lower quality care for Black patients.
You talk about the need to embrace a more holistic view of mental health in the Black community that goes beyond the presence or absence of mental disorders. Can you discuss this point further?
It is really important that all people start considering a more holistic view of health in general. We create these false divisions between different aspects of health, but what makes us think that we need to separate our mind from our body? We have so much evidence that they are very connected and that what happens in our minds impacts our bodies and what happens in our bodies impacts our minds. For that reason, all people, Black people especially because of the number of stressors that they face, should really focus on taking care of the whole self, mentally, physically, and spiritually. Ideally, we would have more health care centers that take this integrated approach. One piece of evidence for this interconnection is the fact that Black people have relatively good mental health overall when we consider their typical life stressors, but often have poorer physical health. It could be that in an effort to preserve their mental health, Black people are harming their bodies. This goes beyond things like a tendency towards eating unhealthy comfort foods when a person is stressed. It appears that for many Black people, negative factors such as stress may not result in mental health problems like depression, but instead would result in physical manifestations such as high blood pressure. With a more holistic view of health, doctors could examine whether there are mental health factors (such as stress from experiences of discrimination) that are leading to physical problems (poor cardiovascular health). That type of treatment approach could help us to reduce health disparities. Further, I am a huge proponent of mental health treatment. I believe that people should get yearly mental health check-ups just like they get physical exams, but the African American community has a lot of stigma surrounding mental health. An integrated approach would help remove this stigma if your mental health check-up is just a part of your regular health care practice.
What are some things about the African American community that members of the health care profession should be aware of in order to provide the best mental and physical health service to members of the community?
The most important thing for health care providers to do is to check their own biases and assumptions. Health care providers must do some soul searching. What do you really think about people of color? Do you expect that they will not follow the doctor’s orders, so why give them anyway? Do you make assumptions about how they live and what they understand without proper assessment? Do you truly listen to their concerns? Do you make an effort to build rapport with all patients equally so that they feel safe and cared for? Further, medical facilities need to start really looking at their practices and making sure that treatment of all patients is equitable. For example, hospitals should keep track of things such as how often patients are given pain medication based on ethnicity. There is an assumption that African Americans can handle more pain and therefore they are denied this medicine. Also, African Americans experiences can often be discounted by medical professions. One example of this is the high rate of deaths by African American women during childbirth. These deaths are often preventable and occur because health care providers may discount the complaints and concerns of African American women. I experienced this first hand and it resulted in the one of the scariest moments of my life. If the only time that health care providers interact with people of color is at work, this is a recipe for poor rapport and low quality care.
Can you discuss the nature of symbolic racism and the role it plays in the current racial dynamic in the U.S.?
Symbolic racism is a subtle form of racism in which people believe that racism is not real and that people of color have not progressed more in life due to their own deficiencies. This is one of the most damaging forms of racism because it is widespread and people can feel good about themselves for having an “American work ethic,” believing they have achieved their goals completely due to their own hard work. What they do not consider is the fact that often, they have had many people and situations help them along the way that people of color have not had. European Americans are more likely than African Americans to have parents that went to college, have parents that own a home and can pass that home down to them, get inheritances from other family members, have teachers that look like them and have similar cultural values, live in a neighborhood that is middle class with access to healthy food and medical care, and see positive images of people who they can identify with in the media. All of these factors are aspects of structural racism and impact health, financial, and educational outcomes. So those who harbor symbolic racism beliefs discount all these factors and the many more that impact the lives of African Americans. These are the same people who ask “well what did he do” when an unarmed Black man is shot by the police because they cannot fathom that the murder could be a result of a system of racism and no fault of the murdered Black man. Such ideas are inherent in those who assume that the Black Lives Matter movement suggests that other people don’t matter. Unfortunately, we have to state that Black lives matter even when WE know that all lives matter; it is just that the United States does not seem to know. For that reason, they need to be reminded, Black lives matter.
Can you discuss color-blind racism and how it impacts the psychology of African Americans?
Color-blind racism is when a person says that they don’t see color so they cannot possibly be racist. This is problematic first of all because it is not true. Perhaps a person may not have biases against other people due to their race or ethnicity, but unless you have some type of disability, you will determine (or attempt to determine) an individual’s race or ethnicity when interacting with them. This is part of being human. We categorize people into ethnicity, gender, age, etc. when we first see them. It is a quick way to get information about who a person is and how you should interact with them. What we must pay attention to is the fact that we often do treat people of different ethnic groups differently, even when we think that we do not. This is the major problem. One important way that color blind racism may sneak into the world of health care providers is through mentorship. When you think of who you have mentored or been mentored by, how often has a good mentoring relationship been with someone of a different ethnic background? Usually it is not. This is because we assume that we are color blind, but biases and expectations often cause us to connect with those who we believe are like us. People may reach out to support others who they can identify with, but if one is being color blind, they can pretend that ethnicity has nothing to do with it, when often, it does. They can say, “well she reminds me so much of myself when I started” and deny the fact that they had biases about the Black nurse and therefore did not reach out to support her. Color-blind racism is also problematic because by trying to discount ethnicity, people are ignoring important aspects of who a person is and often this will result in a poor interaction. This can be particularly problematic for a health care worker who is unwilling to ask the questions that they need to in order to better understand a coworker or patient and is instead just acting on their assumptions.
In your book, you discuss some of the gender based ways that Black men and women react to the experience of racism in the U.S. Can you describe some of these responses?
My text discusses John Henryism—when referring to Black males—and Sojourner Syndrome—for African American women—as coping mechanisms for overcoming the barriers that racism creates to their success. Both ideologies suggest that Black people must work harder to achieve what European Americans are able to achieve in this country as a result of racism. Though these coping mechanisms may result in financial, career, or educational success, they often take a toll on the individual’s physical health through negative impacts on the cardiovascular system. The individual is often under constant stress as they try to overcompensate for the racial barriers that are placed in their way. Another interesting idea that has been put forth about Black women is the Strong Black Woman ideology which suggests that Black women often feel that they must be independent, resilient, and self-sufficient to the point that they often do not ask for help when needed and are ashamed to demonstrate weakness. They have often taken on the more of the burden of supporting their families than Black men because Black men face so many more racial barriers than they do. The Strong Black Woman ideology often is linked with poorer mental health as these women do not seek out support when they are struggling.
What is one area of ongoing research into the psychology of African Americans that you feel excited about and why?
I am excited about any research that works towards improving the outcomes of African Americans across the board. Right now, I am doing work examining mental health stigma, which is negative beliefs about individuals who have a mental health disorder or about treatment of mental health disorders. Mental health stigma is relatively high in the African American community. I am very interested in research that focuses on the best ways to reduce this stigma because it has such a profound impact on treatment. If there is less stigma, more African Americans would be willing to seek mental health treatment. Then the next step for research would be making sure that there is effective and available treatment.
