The Stuff That Is Killing Us

Nov 18, 2014, 1:00 PM

Ronald M. Wyatt, MD, MHA, is medical director in the Division of Healthcare Improvement at The Joint Commission. In this role, he promotes quality improvement and patient safety to internal and external audiences, works to influence public policy and legislation for patient safety improvements, and serves as the lead patient safety information and education resource within The Joint Commission. On December 5, RWJF will explore this topic further at its first Scholars Forum: Disparities, Resilience, and Building a Culture of Health. 

I first met Don Erwin, MD, in 2010. He was CEO of the St. Thomas Clinic in New Orleans. I sought him out on the recommendation of the CEO of the Institute for Health Care Improvement (IHI), Donald Berwick, MD. I was a fellow of the IHI, and Berwick and I had conversed about inequities in the U.S. health care system. He advised me to travel to New Orleans to speak with Erwin, who would give me insight that would be important to the project that I was working on: “Disparity in the Deep South.”

Scholars Forum 2014 Logo: Disparities, Resilience, and Building a Culture of Health.

Erwin was very welcoming and asked why I was there.  In a very academic tone, I told him that I was there to better understand the non-medical determinants of health. With a semi-puzzled look on his face, Erwin asked what I meant. Now I became puzzled and a bit uncomfortable. My response was that I was interested in learning more about the role of social determinants on health.  Erwin said, “Ron, I am not sure what you are talking about.” 

With growing unease and a more rapid pulse, I went on to describe the social issues and conditions that led to poor health outcomes. With that statement, Erwin replied “Oh now I know what you are asking ... You want to know more about what it is that is killing us in the south.” It was time for me to pause and listen. Erwin told me that the only way to begin a discussion about what is killing people is to call it what it is: Racism—structural, institutional, and linguistic—just for starters.

As our conversation continued, I mostly listened. Erwin, whom I had envisioned as the quintessential white southern gentleman, said that racism is the single most critical barrier to improving health outcomes. He discussed how racism has been consciously and systematically erected and sustained. He also said that this can be undone only if people understand what it is, where it comes from, how it functions, and why it is perpetuated. He told me that this was the credo of the People’s Institute for Survival and Beyond and the Undoing Racism training being led by Ron Chisholm. This training is required of all employees on an annual basis in order to be credentialed to work at St. Thomas.

The approach used by the People’s Institute includes the following:

  • Learning from history
  • Sharing culture
  • Developing leadership
  • Maintaining accountability
  • Networking
  • Analyzing power
  • Gatekeeping
  • Undoing internalized racial oppression by removing internalized racial inferiority and superiority
  • Identifying and analyzing the manifestations of racism

The trip from New Orleans back to Cambridge was quite reflective for me. I reflected on the segregated waiting rooms in Greensboro and Marion, Alabama, where I grew up. My mind traveled back to my dear uncle, Tom Cannon, who had died from a ruptured appendix in Selma, Alabama, having not been seen by a physician. I re-watched the “Unequal Treatment” materials and began an ongoing dialog with experts familiar with this issue, including David Williams, PhD, MPH, Harvard School of Public Health; Thomas LaVeist, PhD, the Johns Hopkins Disparity Program; and Yvonne Coghill, OBE, National Health Service, UK.  I poured over the immense amount of data, published research, and my personal experiences from more than 20 years of clinical practice.

I visited the disparities program at the University of Alabama, Birmingham, and the Triple Aim Project on the east side of Chattanooga, Tennessee. There, I asked a program director (a former community organizer and a retired industrial quality controls person) what would most impact and drive action toward sustained efforts to address inequities and disparities in health care. Their responses included: Efforts to confront and remove all the forms of racism that exist and invest in the minority communities.

Such investments meant less research and more use of known data to implement meaningful changes. Examples of change include the following: remove food deserts; improve public transportation; repair sidewalks and street lights; work to remove people from dilapidated public housing; promote more proactive law enforcement engagement; and improve the educational opportunities during and after school (the most critical change on this list.)

 These actions require holding the health care industrial complex accountable for the shameful and embarrassing data that screams out that blacks and other minorities are not receiving equal treatment. The data tells us that if you are black, Hispanic, Asian, American Indian, Alaskan native, other minority, LGBT, elderly, poor or have limited English proficiency, then your health care outcomes are worse. For black people, this is true regardless of income, ZIP code, profession or educational status. We know that black people have lower trust levels for the medical profession.

We know that all too often medical decisions are driven by conscious or unconscious bias and prejudice. I have personally been subjected to a white physician who was openly hostile to me during a procedure.  At the end of the procedure, I asked him if he knew me. He immediately looked at the chart and let out a heavy sigh saying, “You are a physician and a patient safety expert.” My reply was, “no,” that is not who I am. I am a husband, father, a very anxious patient and a human being; none of which was considered when he threatened that if I did not “hold still” I could be blinded by what he was doing. As I waited to be seen that day, I had noticed how kind and courteous he had been to the white patients who were being seen, so I had expected the same. The treatment was not equal.

So, what is the way ahead? I hope that the entire U.S. health care system will declare that the goal is zero inequity and disparity. One way to begin this journey to zero is to develop and implement national equity and disparity goals. These goals must be endorsed by patients, communities, patient advocacy groups, the Centers for Medicare and Medicaid Services, commercial insurers, academic medicine, and public and private health care organizations. There are many existing strategies and roadmaps. We have robust data and measures of equity and disparity. What has been lacking is the will to declare equity and disparity as a public health issue and a moral/ethical issue. Racism and all such “–isms” must be removed if we are to achieve the goals of the Triple Aim: better patient experience, better population health, and lower costs for health care.

As Coretta Scott King stated, we “cannot be big and small at the same time.” Now is the time to go big. If not each of us, then who?  

This commentary originally appeared on the RWJF Human Capital Blog. The views and opinions expressed here are those of the authors.