Racial Inequities in Health Care: What Is Holding Us Back?

In our recent webinar on caring for cardiovascular patients in the face of COVID-19 and systemic racism, Dr. Ronald Copeland delivered the powerful opening remarks.

Copeland has long been involved in issues of race and equity in health care. He is a senior vice president and chief equity, inclusion, and diversity officer at Kaiser Permanente. “It’s my privilege and honor to be part of today’s discussion,” he told the CCI panel and guests. “I was really thrilled to see what you all have contributed to this work, particularly in relation to the impact of racism. You’ve also highlighted how difficult and challenging it is for us to achieve health equity.”

In his opening remarks, which have been edited for length and clarity, Copeland put the discussion in a context of a history that is all too relevant today.

This is really a call to action, and what I want to do is ask this provocative question: What will it take? What will it take for us to use the knowledge, the awareness of the role that inequity plays in people’s day to day lives and the health care we deliver?  What role does it play in the outcomes and improvement opportunities that we’re pursuing? Is it the lack of knowledge or the lack of motivation? What is holding us back from a breakthrough? I just want to refer back to our past and elevate that as we contemplate and chart our course going forward.

Many of you may remember that in 2003, the Institute of Medicine published a landmark report that was called “Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare.” The authors did a comprehensive assessment of all the factors they could identify that might contribute to disparities in health experiences and health care outcomes. This included those that were developed and perpetuated within the health system, whether it was lack of effective communication, lack of culturally responsive care, the impact of bias, lack of resources, or the lack of appropriate representation reflecting the composition of the community they served. It included factors that were external to the health system — factors that had an impact in people’s access, affordability, socioeconomics, and living conditions on a day-to-day basis.

In that report, the authors made many observations about what the drivers were and recommended some comprehensive strategies be put together. These involved payers, health care system physicians, and community members who would try to figure out how we close that gap. A lot of our systems and our leaders paid attention and were motivated to begin the journey of saying, how do we incorporate culturally responsible care in our organizations? How do we take on the issues of implicit bias, and how do we understand disparity gaps and then try our best to close those gaps?

You’ll hear a lot from some of our presenters today about what they’ve learned in those journeys. Yet if you fast forward to the current situation, the challenge we found was even though that report was comprehensive and done in 2003, here we are today at 2020. And we see once again the stubbornness of these disparities still existing within our health care systems. Even for those of us such as Kaiser Permanente, which demonstrated the ability to narrow gaps and in a few cases to actually close gaps, we still know that there’s much work to be done. Taking that on will create new options for the future.

So we are now in a situation where we’re facing COVID. And once again, we see data that tells us that Black, indigenous and other people of color are again highlighted as having disproportionate levels of infection and hospitalization rates and, unfortunately, disproportionate death rates as well. So once again, what we documented years ago still haunts us today and is consistent. So for me, what that asks is the question: What are the drivers that are unaccounted for in the way we’ve been thinking about this and the way we approach it?

And I think there’s a new awareness emerging because of the social injustice and unrest that’s on going on. It has brought it to our attention, if we weren’t already there, that systemic racism, oppression, and discrimination — not just by individuals, but built into the fabric of policies practices — are impacting people’s day-to-day lives in ways that make it economically difficult, that predispose them to vulnerabilities related to trust and trauma, and to massive incarcerations that destroy family situations. All those factors are in fact, having an impact as key drivers of the health outcomes of the patients and the communities we care for.

But what is our role in taking on those issues? How do we play a role, and not just as physicians with medical degrees and an understanding of science? What is our commitment and our role to take on the issues of social justice and systemic racism? I’m reminded of a quote from W.E.B. Du Bois, a sociologist who back in 1899 was describing one of the factors that still needs to be accounted for in our country today. Du Bois said, “The most difficult social problem in the matter of Negro health is the peculiar attitude of the nation toward the well-being of the race. There have, for instance, been few other cases in the history of civilized peoples where human suffering has been viewed with such peculiar indifference.” He was making reference to apathy — that people were aware of the plight and suffering of others, but for some reason felt they are not feeling compelled to take these issues on and to challenge the systems producing them.

So I asked myself and I asked all of you to think today, what will it take?

I’m just going to rattle off a few suggestions, which I’ve shared and learned with others. From our perspective, these are the really critical things we need to do individually and as systems to make a difference and to break through this struggle we have dealing with health inequities and disparities.

First, we need to recognize that our impact goes beyond the walls of our various institutions and our exam room — and we have to get comfortable declaring that systemic racism, neglect, and oppression are determinants of health. There are reams and reams of data that confirm that every day. So we have to acknowledge and confront this formidable task that stands in the way of our progress.

This has been a very, very challenging thing to do. People’s reluctance to take this on is understandable, but it’s not acceptable. We have to challenge this peculiar indifference and apathy [toward racial justice] and activate true allyship. We have to understand that we are each other’s keepers and the environments we create need to create fairness and equity for all of us, not just some of us. We have to lead unapologetically, with courage, compassion, and integrity, and challenge our respective institutions to do.

In addition, we’re going to have to create coalitions with likeminded individuals and community partners to develop innovative and holistic interventions. We’re going to need to marshal resources, those that we have control over and those that we can influence based on people’s need rather than their privileged situation. We have to make health equity a moral and strategic priority, integrate it into our quality improvement activities, and leverage technology solutions to close geographic gaps, monitor progress and create data transparency so that gaps can be identified and addressed in a timely fashion.

Equally important, we need to co-design solutions with the people that we are here to serve and honor those who are providing that service. We know that there’s a tremendous rising trend, a disturbing trend of burnout and suicide attempts [among care professionals]. There have been cases of suicide among health professionals even before COVID arrived, and it’s now been aggravated even further. So creating and enabling support and self care for those providing care and reflecting the makeup of our communities is a critical action for us as well.

So in conclusion, I just want to say, as we go into this day of discussion, that I don’t believe we can achieve health equity without addressing racism, courage that requires self-reflection on one’s ethical and moral compass, and a conscious decision to serve a cause greater than our individual selves. It takes personal conviction to overcome fear. And nothing is more powerful in that journey than being an active listener of the powerful stories our patients and communities have to share with us about what it is like to undergo and experience injustice on a steady basis — and then to somehow overcome it with the help of allies and appropriate resources.

This is about confronting injustice and refusing to give in until that victory is achieved. Our patients don’t want us just to be excellent medical scientists and physicians. They want to need us to be champions for health equity as well. So let me close my comments today with two quotations that speak to the last element of our challenge ahead: the issue of power and how power must be addressed as part of this equation as well.

Frederick Douglas, a freed slave and abolitionist, once made the statement: “Power concedes nothing without a demand. It never did and it never will.” And last but certainly not least. I’d like to end by reciting a quote from someone gone too soon: the recent CEO of Kaiser Permanente, Bernard Tyson, who encouraged all of us and inspired us to say: “Don’t ask permission to help improve the lives of the people and communities you’ve pledged to serve. Instead, march through the doors of red tape, make bold moves, and usher in access for your communities to be served.”