February 28, 2020 at 05:00PM by CWC
I spent 16 years (from 2002 to 2018) at Columbia University as a resident, fellow, and practicing reproductive endocrinologist. In my time there, I watched approximately 90 residents get their starts as OB/GYNs, but only a handful of us were Black. Recent research echoes this dynamic: As of 2017, less than 6 percent of physicians and surgeons in the U.S. were Black.
In my practice, I’ve heard countless patients of minority backgrounds (particularly Black women) say that they’ve been wanting to see a doctor who shares their background and have been searching for that fit—sometimes for many years.
Why? Black women of all socioeconomic strata are impacted by racial bias in medicine and beyond—and much of it boils down to systemic injustices, stereotypes, and outward appearances. Though we’ve certainly made progress since the studies on Black patients without consent from the mid-20th century, we still have a very long way to go.
Without increased representation of persons of color as health-care providers and more education about racial bias, the cycle of disparity is perpetuated. But just because this might be the current reality doesn’t mean that Black women can’t have positive medical experiences. By unpacking the issues and learning where they stem from, Black women can better advocate for themselves—and have others advocate for us, too—in the future.
The real disparities that exist in Black women’s health
When there’s a health disparity in a specific population, that means that a specific group of people has a higher overall rate of unwanted health conditions and outcomes (disease incidence, prevalence, morbidity, or mortality), and a lower rate of provided health-care services and treatment compared to the general population. Though there are many populations that experience disparities in health care, Black women are among the most affected, particularly when it comes to reproductive and sexual health.
The starkest example: Black women’s maternal mortality rates are three to four times higher than white women’s—and these deaths are mostly preventable. In a report released in 2019, the Centers for Disease Control and Prevention (CDC) monitored pregnancy-related deaths in the U.S. from 2007-2016 and found that Black women were more likely to die of cardiovascular-related pregnancy complications compared to white women. For example, 14.2 percent of Black women died from cardiomyopathy (heart muscle disease that makes pumping blood more difficult) as compared to 10.4 percent of white women.
On the other hand, while the percentage of Black women who experience infertility is higher than white women, the American College of Obstetricians and Gynecologists (ACOG) reports that fewer Black women receive infertility treatment. An estimated 11 percent of Black women receive infertility treatment as compared to 16 percent of white women. In one 2015 study of 1,073 women of reproductive age, researchers found that Black participants with fertility issues were 75 percent less likely than white participants to seek help from a doctor—and of those who did seek help, they waited about twice as long as white participants to do it.
The issue goes beyond fertility and pregnancy. People of all races who experience pelvic and menstrual pain (due to conditions like endometriosis or uterine fibroids) are often told that it’s simply a natural part of being a woman. However, a 2012 meta-analysis of pain management and racial bias found that Black patients who reported pain were 22 percent less likely to receive medication to treat it.
According to the American Cancer Society, the lifetime probability of Black women developing breast cancer is 11.5 percent as compared to 13.2 percent of white women —but there’s a slightly higher lifetime probability of Black women with breast cancer dying from the disease. JAMA Oncology found that Black women also had higher odds of being diagnosed with breast cancer at advanced stages.
While it’s true that socioeconomic factors can have a major impact on reproductive health outcomes and disparities, negative experiences aren’t exclusive to women of lower income levels. Take Serena Williams, a person whose wealth and status grants her access to the best care possible. Yet even then, she says that she was first ignored by her health-care provider when she felt signs of pulmonary embolism the day after her cesarean section.
Why do these disparities exist?
There are many factors that contribute to this massive problem. But in my experience as a health-care provider, two that I believe have the biggest impact are systemic racism and implicit bias.
Systemic racism has an impact on many aspects of our lives—and health care is no exception. This problem is systemic in the truest meaning of the word: Historic injustices based on racial discrimination still influence us today because they’re actually built into many of our institutions. Per the American Academy of Family Physicians, the health-care facilities that exclusively served racial and ethnic minorities in the past continue to operate with limited resources. This has a trickle-down effect on the health outcomes of patients. In the case of maternal mortality, hospitals that serve primarily minority patients tend to have higher occurrences of complications during delivery than predominantly white hospitals, in part as a result of financial constraints
Additionally, while segregation and discrimination in hospitals and clinics are no longer legal, discrimination based on insurance status is, which disproportionately affects Black Americans. As of 2017 (the most recent data available), 55.5 percent of Black people in the U.S. have private health insurance (as compared to 75.4 percent of white people), while 43.9 percent rely on Medicaid or public health insurance (as compared to 33.7 percent of white people). Meanwhile, 9.9 percent are completely uninsured (as compared to 5.9 percent of white people).
Further complicating matters is the reality of implicit bias—meaning the attitudes and stereotypes in our subconscious that affect how we view and treat people—and how that impacts the care that Black women receive. In one cross-sectional study of 40 doctors and 269 patients in “urban community-based practices,” researchers found that race bias against Black patients was associated with doctors asserting more dominance in conversations, patients rating their experiences poorly, and doctors focusing less on the patient. Bias contributes to Black women not feeling heard, and as mentioned above, to their pain and concerns being dismissed by health-care practitioners. The lack of Black doctors certainly doesn’t help.
But even training more Black doctors—a worthy and necessary goal—isn’t a perfect solution, because Black physicians are expected to solve racism on their own. “They are often expected or told to execute ‘diversity’ efforts such as chairing diversity committees, mentoring minority trainees, and the like, and then are rarely recognized or compensated for this invaluable work,” argued Uché Blackstock, MD, (a former med school professor) in a recent essay. Even when Black doctors do take on these additional duties, Dr. Blackstock wrote that they still get fewer mentorship, sponsorship, promotion, and advancement opportunities—evidence that bias exists among colleagues, too.
What can be done to move forward
The onus belongs to the entire medical system (schools, hospitals, and the government) to fix the problems that afflict both our colleagues and patients, from providing more training to reduce bias, funding research into health issues that affect Black women, and partnering with government bodies to push through meaningful legislative changes. Thankfully, organizations like Advancing Health Equity, Center for Reproductive Health, Black Mamas Matter, and the Association of American Medical Colleges are stepping up to effect change and put an end to health-care disparities.
While we can’t undo years of systemic racism or implicit bias on our own, women can also make changes in the meantime that help them have positive, productive engagements with health-care providers. I always recommend that patients document everything (their experiences, symptoms, etc) and put them in a calendar or diary to show frequency, pain scale, and anything that provided relief. Knowing your symptoms well will help you present them clearly to your doctor. And I always urge people to interrupt their doctor if they have any questions or if they don’t understand something that’s said. You’re there to have your needs met—do what it takes to make that happen.
In my experience, the vast majority of doctors enter the health-care industry because they want to help people. I believe that if we continue to educate the doctors we have about implicit bias, encourage and support more Black women and men to become doctors, and always strive to advocate for what we need from our providers, we can work together to build a more positive future of health care.