Improving health inequalities by recognizing structural racism


In early spring, Kimberly D. Manning, MD, FACP, FAAP, cared for a large black man with multiple comorbidities a Grady Memorial Hospital in Atlanta, gathering a drug order and a discharge plan.

“It was very difficult,” recalled Manning, professor of medicine and associate vice president of diversity, equity and inclusion at Emory University, Atlanta, during a May 4 session at SHM Converge, the Society of Hospital Medicine’s annual conference .

At one point, the patient looked at her, shrugged, and said, “You know, Doc, let’s get in where we fit.”

Dra. Kimberly Manning

“I was talking about the idea that people who come from historically disadvantaged backgrounds should just try to figure it out, they should try to earn a 15-cent dollar,” Manning said. “That, to me, really underscores what we mean when we talk about health inequalities, this idea that there are people who are working hard and doing the best they can, but who are still forced to ‘get where they fit in.’ . “

Disease control and prevention centers define health disparities as preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health experienced by socially disadvantaged populations.

“When we think about health disparities we often think of a lot of diagnoses,” Manning continued. “We think about it HIV and the disparate attention and results we have seen in populations of individuals coming from minority backgrounds. We see disparities obesity, cancer, cardiovascular disease, infant mortality and maternal death, hospital readmissions and COVID-19. We know that people who do not have access to health care or to healthy neighborhoods and environments or who are at a financial disadvantage have worse outcomes. It develops with all these diagnoses “.

In his view, health disparities in hospital medicine lie in one of three cubes: diagnosis and triage, hospital stay, and treatment and landing – “that is, after a patient leaves the hospital,” he said. explain Manning. “Staying in the hospital is the turn of the balance bar. You can do everything perfectly, but then you have to disassemble. To score a ’10’ you have to stay on the landing. That means to be able to get your medicines, to be able to get them to and from appointments at the clinic, to be able to understand the indications they have given you. All these things are intertwined, hospital care and outpatient consultation. “

The roots of health disparities in hospitalized patients come from centuries ago, he said, when the U.S. health care system was built to benefit white male landowners and their families. Health care for blacks, on the other hand, “focused on function, almost like veterinary care or experimentation,” Manning said. “When slavery ended, many historical black institutions of higher learning were opened, including medical schools. In 1909, there were seven historically black medical schools. Recognizing the history that preceded the disparities is essential.”

In his view, the path to improving healthcare disparities begins with admitting that structural racism exists in the practice of medicine. “This means that health disparities are related to systemic and individual problems, including our biases,” Manning said. “Our system was based on the idea that there is a greater value of one group of people above others. Access to care, the workforce of doctors and biases are affected by design. “Equity in health and equality in health are not the same.”

He also stressed the importance of the social determinants of health, or “those things we need to be healthy,” including economic stability, neighborhood and physical environment, educational opportunities, access to good nutrition, community and social context and the idea of ​​health care as a human right and understanding of our health system. “That’s what’s needed,” he stated. “Without all of this together, we can’t have the health outcomes we want.”

As hospital leaders work to build a more diverse workforce, Manning emphasized the importance of forming anti-racist policies by addressing issues such as what will we not advocate? How will we protect and create psychologically safe environments? What is our commitment to diversity in leadership and practice? What is our commitment to implicit prejudice training and spectator training?

“We need to feel uncomfortable enough to defend urgently because all of these are necessary factors to mitigate health disparities,” he said. “While systemic problems are the most urgent, on an individual level, we must continue to upset the negative ideology and stereotypes that threaten our environment every day. When we see these negative things, we must summon them. We must continue to listen, humanize those things that happen around us and understand the historical context “.

Manning reported that he had no financial disclosures.

This article originally appeared on, which is part of the Medscape professional network.

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