Racial equity in healthcare: turning Martin Luther King Jr's dream of racial equality into a 21st century reality

Abstract

Racial equity should be a universal goal in health. Unfortunately, people may not have the same opportunity for good health, but they should have equal rights to good healthcare. Overcoming inequities and improving a sense of diversity, community and belonging for all cultural groups remains an ongoing priority for the health system. This article discusses the different forms of racial inequity that may exist within any given health system, offers examples that may signal its presence within healthcare institutions and highlights interventions that aim to reduce racial inequity at both a systems level and for individual healthcare workers.

I have a dream that one day this nation will rise up and live out the true meaning of its creed … that all [people] are created equal.

Martin Luther King, Jr ¹

In a speech delivered on 28 August 1963, during the height of the American Civil Rights Movement, Martin Luther King Jr outlined his dream for racial equality. This enduring call to action still resonates deeply for people who aspire towards achieving a healthcare system that aims to reduce inequities in healthcare influenced by bias arising from differences in race and ethnicity.

An ideal health system is founded according to the fundamental principles of fairness and justice: the lives and voices of people who use a health system should be of equal worth regardless of ethnicity, education or socioeconomic background, and so too should the voices of the people who work within this system. Unfortunately, people are not born ‘equal’, as they do not necessarily have the same opportunity for good health, but they nevertheless should have equal rights to healthcare. Equity, which is closely related but not the same as equality, represents the idea of recognising that not all people have the same access to the resources they need. ² While equality argues that everyone deserves the right to be on a metaphorically level playing field from the beginning, equity accepts the reality that this is not the case and aims to address this by striving for equality in outcomes. Towards this goal, and especially in terms of delivering equitable healthcare outcomes, programmes that aim to improve equity in patients who experience social disadvantage acknowledge that these groups often require more help and resources to achieve relative parity in outcomes when compared with mainstream users. Examples of social disadvantage include geographical distance, education and wealth, but they also importantly include barriers arising from racial bias.

Overcoming racial inequities and improving a sense of diversity, community and belonging remains an ongoing priority in healthcare. ³ Concepts of privilege, ⁴ racial bias, ⁵ structural bias, ⁵ positionality, tokenism ⁶ and microaggressions ⁷ (Table 1) are now being increasingly taught in humanities subjects in tertiary education, but generations of healthcare workers have not received formal didactic or practical training in these important concepts during medical school. While there are now significant attempts at raising awareness, this remains crucial in helping people understand the complex social dynamics among those who form, engage and interact with the health system, how inequity can arise and how this can be redressed.

Table 1.

Definitions

Racism: A form of discrimination directed against an individual or group of people on the basis of their membership of a particular cultural group or ethnicity. This discrimination can be overt or covert. This is not limited to behaviours and attitudes directed from dominant social groups towards ethnic minorities, but can also be bidirectional and also occur between different minorities. The reasons for such behaviour are multifactorial but fundamentally arise from a conscious or subconscious belief system that one race possesses distinct intrinsic attributes that confer inferiority or superiority compared with another. This is sometimes euphemistically referred to as cultural bias. Structural bias: Structural bias refers to the means by which institutions have been designed to benefit one group over others. Examples include systems that require a certain level of educational attainment, language literacy, restrictive policies or procedures, or even governance procedures. Interventions in providing culturally responsive healthcare and improving accessibility of healthcare for Indigenous Australians are an example of overcoming structural bias. Microaggressions: These consist of subtle behaviours that convey negative attitudes towards people belonging to marginalised groups. Examples of microaggressions against people of different cultural groups and minorities include avoidance, ignoring, dismissing concerns and invalidating experiences. Positionality: a concept which explains how the intersection between people's sense of identity and belonging to a group (e.g. gender, race, class, ethnicity, ability, geographical location) and their own lived experiences influences their worldview and how they interact with others. Privilege: a special right or advantage available to one group but not others. This manifests as differential access to resources and social opportunities. Tokenism: a practice of appearing to offer equitable endeavours through superficial or symbolic efforts. Common examples include (i) recruiting a small number of people from under‐represented groups in order to provide the appearance of diverse representation and (ii) focussing efforts on improving equity only for certain groups while investing fewer resources in others.

Table 2 outlines common signs that racial inequity may exist in a healthcare or workplace setting. Racial inequality in healthcare can be divided into:

1. Patient experiences: Patients from certain ethnic or cultural groups may find it easier to access healthcare, while others (often those from minorities) find the same access significantly more challenging. ⁸ Patients from cultural minorities may find it harder to gain access to healthcare, feel uncomfortable asking for help or are treated differently because of their ethnicity or cultural background, which then results in negative impacts on physical and psychological well‐being. ⁹ These experiences may occur as a result of direct interactions with health staff or system. A well‐known example is the significant evidence of the deleterious impact of racial bias in healthcare settings for Indigenous Australians. ¹⁰ , ¹¹

2. Healthcare worker experiences: The healthcare system consists of a community of individuals from diverse cultural backgrounds. Healthcare workers from different ethnic backgrounds may experience bias, either from patients or in staff‐to‐staff interactions. Overt forms of racism or cultural bias may occur, but it is also important to recognise less overt forms of bias, including microaggressions (definition in Table 1). Instances of bias among healthcare workers are likely under‐reported, especially if workers are fearful of recrimination or career progression if they speak up, ¹² and this can lead to the perpetuation of racist attitudes and structures.

Table 2.

Red flags that may signal the presence of racial inequity in healthcare

There appear to be barriers to getting the same medical care in the same institution for a patient who identifies as belonging to an ethnic minority compared with another patient belonging to another group.

When workers from ethnic or racial minorities do not feel that their voices are being heard or that their concerns are being ignored.

When patients or staff appear to listen to staff from one ethnicity or racial group more readily than to others.

Lack of diversity or multicultural representation in committees, decision‐making bodies or selection panels.

Absence of ethnic diversity in the public media or when an organisation's social media sites feature mainly people from a single ethnicity, especially if that ethnicity is the dominant cultural group.

System‐level approaches aimed at achieving equity in healthcare

1. Education: The principles of racial equality and racial equity should be taught and reinforced at all stages of professional development and training, and not be considered a stage of enlightenment that is achieved after years of life experience. The Royal Australasian College of Physicians is now making activities relating to addressing cultural safety and health inequities a mandatory component of the continuous professional development curriculum. ¹³ While there have been significant efforts in providing cultural training over the years in medical school and specialist colleges, including important interventions aimed at improving health equity for Indigenous Australians, there are data to suggest that there is still much room for improvement. ¹⁴ While education is important for all age groups, embedding cultural training among trainees and younger healthcare workers, who represent the future of the healthcare system, is particularly important as it provides a key mechanism for the long‐term removal of racist ideologies and structures.

2. Celebrating awareness days: Harmony Day (21 March) is celebrated in public hospitals across Australia. ¹⁵ This is an important first step in ensuring that the conversation about racial equity for patients and staff should be at the forefront of professionalism and core values and that we should celebrate diversity and be mindful of cultural inequities every day of the year.

3. Being aware of examples of tokenism (see definition in Table 1) and its potential impact in endeavours aimed at achieving true racial equity: True racial equity requires that effort, resources and attention be fairly offered to all culturally disadvantaged groups. Symbolic or superficial efforts may help, but if leaders believe that such efforts alone are sufficient, this can unfortunately serve to perpetuate the disadvantage of the cultural group that such intervention was meant to help, as well as perpetuate the disadvantage of other cultural groups that have not been given attention. Table 3 outlines effective strategies that can address racial inequities in healthcare.

Table 3.

Interventions that address racial inequities in healthcare

Formal education: Cultural awareness and training should be incorporated into the curricula of medical school, prevocational and vocational training.

2 Promoting agency among members of ethnic minorities: Senior or established clinicians may feel more comfortable speaking out against overt examples of racial or cultural bias.

3 Adopting a pragmatic not combative approach: Addressing bias requires a professional approach that aims to address the issues constructively. Direct confrontation with overt bias often may not produce desirable results. An adept approach often involves deftly defusing examples of bias, aiming to find common ground – this equates to patient safety and achieving ‘good’ patient outcomes – and subsequent escalation of concerns when patient and staff safety is guaranteed.

4 Utilising existing policies and procedures in order to achieve fairness for ethnic minorities: Hospital policies and procedures generally serve to promote fairness – guidelines exist so that patient care is offered according to established standards. For clinicians who believe that their patients are not receiving equitable care, one option is to escalate concerns according to existing guidelines, policies and procedures. Reminders of standards of care and practice will hopefully help to encourage equitable care for all patients.

5 Improving ethnic diversity among decision‐makers: This often helps to avoid the pitfalls of groupthink and adds more perspectives to the table, leading to broader discussion and more equitable decisions.

Practical considerations for healthcare workers

Dealing with cultural bias and racial inequity within the healthcare system, whether it is individual or structural, explicit or implicit, overt or covert, can be a particularly challenging, charged and triggering topic for many individuals. It is important to recognise that there will be a wide variety of perspectives, and appreciating the positionality of different parties is crucial to achieving practical solutions. As an example, individual healthcare workers and their patients will interact with this bias differently depending on their own lived experiences.

There should always be zero tolerance for cultural or racial bias, ³ as it has the potential to cause significant distress and patient harm. While there is no excuse for cultural or racial bias, it may be important to realise that such viewpoints may be the product of an individual's upbringing and life experiences (which may include trauma). This is not to excuse such behaviour but an attempt to understand the positionality (definition in Table 1) of both parties may help facilitate challenging interactions. Nevertheless, a pragmatic approach is required to help guide staff and patients who experience cultural bias in healthcare settings. Safety, to both patients and staff, is paramount. This may require affected individual(s) (e.g. staff or patients) to be moved to a safer environment while issues are being resolved.

The role of senior clinicians in championing racial equity

Senior clinicians are important role models for the entire healthcare ecosystem and can be positive agents for social change. Health staff from minority backgrounds often do not speak out against cultural bias due to fear; many who experience racism and cultural bias work in junior positions and may have legitimate fears that raising their concerns will limit career progression or continued employment. Senior clinicians, by virtue of their seniority and experience, hold a privileged position that may allow them to navigate more adeptly challenging conversations across the intersection of privilege and ethnicity. This is particularly the case for senior clinicians from ethnic minorities. These clinicians, who have navigated the complex minefield of structural bias and racial inequity throughout their careers, can serve as powerful agents of change in the struggle for racial equity in healthcare. Examples of how they can assist include: role‐modelling for junior staff, representation and reframing challenging discussions so that the outcomes are fairer for both patients and staff alike. Nevertheless, speaking up against cultural bias should not be the sole responsibility of senior clinicians from ethnic minorities and should be considered the collective responsibility of all healthcare workers, irrespective of ethnicity or seniority.

Conclusion

Racism and cultural bias seriously hinder the provision of equitable healthcare. Efforts aimed at improving racial equity (Table 3) should be the collective responsibility of all healthcare workers, managers and administrators. These system‐wide interventions and practical tips aim to reduce existing structural and interpersonal barriers and will likely help Australia's health system realise a dream where healthcare is fair and accessible for all.