‘Break the bias’: Steps endocrinologists can take to improve health equity
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Improving health care equity and access for Black Americans and other underrepresented groups requires a comprehensive approach that goes beyond health system-level changes, including recognition of a painful history of structural racism.
“To comprehensively address health and health care disparities in diabetes and endocrine disorders, we must address not only barriers to high-quality care in the health care environment, but also social determinants and influencers of health — the built environment, economic empowerment and high-quality education,” Sherita Hill Golden, MD, MHS, the Hugh P. McCormick Family Professor of Endocrinology and Metabolism and vice president and chief diversity officer of the office of diversity, inclusion and health equity at Johns Hopkins Medicine, told Healio. “Collectively, this multi-pronged approach will enable us to achieve health equity for all marginalized communities.”
Historical structural racism has contributed to how disparities in diabetes are viewed by the medical establishment and society as a whole, Golden said during the Clark T. Sawin Memorial History of Endocrinology Lecture, presented virtually during the ENDO annual meeting. To make progress and improve patient care, clinicians must learn about the events that set in motion generations of unequal treatment. For endocrinologists, that includes a history of racist views regarding who develops type 2 diabetes and why.
A ‘disease of the civilized’
Race has informed how people with diabetes have been viewed during the past 150 years, Golden said.
In the 1860s, Jewish people who immigrated in the United States were believed to have higher rates of type 2 diabetes because of an “increase in nervous system activity,” that led to insulin resistance and the development of diabetes; the theory was challenged in the 1930s as it became clear diabetes development was related to weight gain.
After the discovery of insulin, diabetes came to be viewed as a “disease of the civilized upper class,” or a disease of overindulgence among the wealthy, who could now “eat what they want without consequence,” Golden said. Eugenics theory even made an exception for diabetes, as it was believed those with the disease still possessed higher intelligence and moral character. In the early 1900s, diabetes among Black Americans was considered rare; research now shows there was an underestimation of disease burden, in part due to lack of access to health care and inaccurate death rate reporting.
“In the years between World War I and World War II, [diabetes] was considered a ‘clean’ disease of whites, and [Elliott] Joslin even defined ‘good’ vs. ‘bad’ patients with diabetes, attributing poor glycemic control and complications to a personal failure and a lack of moral character,” Golden said.
Over time, the link between diabetes and wealth was questioned. In the mid-1930s, U.S. health survey data showed that diabetes was more likely among those who were economically disadvantaged and that diabetes incidence rose as poverty rose.
“I, too, was quite surprised by the evolution of how diabetes was viewed, as it was initially seen as a disease of the wealthy and highly educated, to being a disease of minoritized and marginalized populations,” Golden told Healio.
As conditions improved for Black Americans, it became clear diabetes rates were still rising, but the disease remained underestimated among minority groups.
“Because this was still considered a disease of civilized white Americans, Blacks were not believed to have the highly sensitive nervous system and the high intelligence that would put them at risk for diabetes,” Golden said. “They were thought to be ‘dull’ and uncivilized. Middle class Blacks, who probably had the same risk factors as middle class whites, were ignored, and not really counted or addressed in the medical literature.”
Increased visibility
It was not until the publication of the Heckler Report on Black and Minority Health, released in 1985, that diabetes and disability in Black communities, along with disparities among Native American, Hispanic and other underrepresented groups, would become fully visible for the first time. The report laid bare stark statistics: Six causes of death accounted for more than 80% of mortality among Black Americans and other minority populations, including diabetes, which was 33% higher in Black compared with white populations. The report led to the establishment of the NIH Office of Minority Health in 1986, more inclusive data collection techniques, and the establishment of state and local minority health offices, among other changes.
But more than 35 years after the Heckler report, inequalities persisted, Golden said. In the 2003 Institute of Medicine report titled “Unequal Treatment,” the authors highlighted that members of ethnic minorities continue to have less access to preventive care, treatment and surgery, leading to delayed diagnoses and more advanced disease, as well as a persistence of race disparities in health and health care. Language and communication barriers also persist, as well as provider bias toward minority patients.
“We often say that certain minority populations distrust the health care system; we put the onus on them,” Golden said. “In fact, it has been the medical establishment that has violated their trust and needs to earn their trust back.”
Become an ally
Several interventions have been shown to be effective in reducing disparities and achieving greater health equity at the individual and health system level, Golden said.
“First, we want to break the bias habit and really become an ally,” Golden said.
Clinicians should work to recognize, label and challenge stereotypes, consider the opposite when data do not support a stereotype, and identify counter-stereotypical exemplars.
“It is important to perceive variability. Hispanic, Native American and Asian communities have been lumped together as one race, when in fact there is a lot of variability among them as it impacts their health,” Golden said. “Providers should also practice common identity formation through perspective taking: What is it like to walk in the shoes of your patients with diabetes who deal with these social challenges?”
At a health system level, institutions should implement the national CLAS standards, a framework to deliver services that are culturally and linguistically appropriate and respectful, and that respond to patients' cultural health beliefs, preferences and communication needs.
“This is really important for addressing the social determinants of health and the interventions that we use to address them,” Golden said.
Advocacy and policy are also critical elements of any solutions, she said.
“As physicians, and particularly as endocrinologists, we maybe have not thought about this as much, but we need to think about it more,” Golden said. “The Endocrine Society has a very active advocacy arm. When I think about my lifetime, our civil rights movement never went away, it just evolved and expanded to include other groups.”
In a question-and-answer session, Golden also said underrepresented medical students and residents must be exposed to endocrinology early in their training as part of an effort to increase workforce diversity in the specialty.
“So many of the diseases of our specialty impact marginalized communities,” Golden said. “This may require loan forgiveness and financial support, as certain specialties, like cardiology or gastroenterology, have higher pay.”
Perspective
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Ricardo Correa, MD, EsD, FACE, FACP, CMQ
COVID-19 highlighted the health care disparities that vulnerable populations, especially those with diabetes, face every day. Vulnerable populations include patients who are racial or ethnic minorities, older adults, immigrants or refugees, those who are socioeconomically disadvantaged, people with disabilities, the underinsured, those living in rural places, the incarcerated, and those with certain medical conditions. These populations face greater complications from stigmatization, affecting their physical, mental, emotional and social health. The lack of economic resources, language barriers, poor access to health care, mobility challenges, and fear of seeking treatment due to immigration policies all contribute to increased patient vulnerability.
Each of the communities mentioned above have their own requirements; it is important that when we talk about addressing disparities and systemic racism in endocrinology, we bring representatives that are expert in this from each community to the table, who can understand the background of the problem in diabetes and endocrinology. We need to empower the endocrine community to apply effective measures for maintaining communication through a culturally appropriate process.
Our endocrine organizations and national, regional and local political leaders must prioritize the health in endocrinology and diabetes of the marginalized communities and be positioned to protect them to not only survive but thrive today and for generations to come.
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Hill Golden S. The lessons learned from the history of identifying and addressing health disparities in endocrinology and diabetes. Presented at: ENDO annual meeting; March 20-23, 2021 (virtual meeting).
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