Breaking barriers and the systems contributing to medical mistrust is the present focus of healthcare in the United States, stemming from its deep history of medical bias. Bias “refers to the various social stereotypes and judgments that people unknowingly assign to others based on a variety of factors, such as age, socioeconomic status, gender, race, or sexual orientation” (Maryville University, 2023, para. 1). Our lived and learned experiences develop biases. While not always negative, they often guide people’s interactions with others and are problematic when not addressed. Medical bias is harmful because patients are impacted by preconceived notions their medical providers carry. Presently, we are discovering how the history of medical bias has impacted vulnerable populations. Throughout this paper, we will discuss some events that exposed the prevalence of bias in the medical field.
The unethical practices within the field of women’s healthcare contributed to the development of medical mistrust. Dr. James Marion Sims, also known as the “father of modern gynecology,” was the first to study and explore the field of women’s health without any established ethical guidelines to follow. The lack of ethical guidelines allowed Dr. Sims to operate on enslaved women, violating their autonomy and inflicting unbearable pain. Through non-consensual experiments, he developed tools to examine women and pioneered some gynecological surgical procedures. From 1845 to 1849, he became infamous for his experiments on enslaved black women in Alabama. He performed vesicovaginal fistula surgeries, a procedure to repair abnormal openings after childbirth. Sims did not give the women anesthesia because of the narrative that black people did not feel pain, an example of a detrimental bias. The lack of concern for the pain inflicted upon black women in these inhumane procedures led to the inaccurate notion that black women do not experience pain to the fullest extent. This event was one of many unethical practices affecting vulnerable populations.
Another prominent event that deepened medical mistrust and racial disparities was the Tuskegee Syphilis Study in 1932, which was approved by the U.S. Public Health Service and conducted a study on black men diagnosed with syphilis, (Alsan & Wanamaker, 2018). Mistrust not only leaves a legacy of irresponsible practices, but the same practices also become a fabric in systematic modern-day policies. And although penicillin was later discovered as the cure for syphilis, the destruction of families due to the communicable disease and exposure highlighted the unethical practices that eventually led to the development of new guidelines regarding ethical research on human subjects.
Two years following the end of the study, in 1974, the National Research Act was signed into federal law and established the Commission for the Protection of Human Subjects of Biomedical and Behavioral Research (Centers for Disease Control and Prevention, 2021). The purpose of this act was to establish guidelines to be followed when conducting ethical research, such as the requirement of obtaining informed consent and receiving approval for studies by Institutional Review Boards (IRBs) (Centers for Disease Control and Prevention, 2021). This act led to the creation of the Belmont Report five years later, which identified basic ethical research principles (Czubaruk, 2020).
Despite the efforts in breaking biases and twenty-five years after the Belmont report, medical biases still exist and are among the number reason premature deaths occur in minority populations. The Institute of Medicine (IOM) identified medical errors as one of the leading causes of death in the United States and attributed the errors to systematic flaws. The 1999 report titled “To Err is Human” was published and called for the development of the National Center for Patient Safety (NCPS) and new systems focused on quality improvement and risk mitigation (Donaldson, 2008) was put in place. While this report identified the problems within the healthcare system, it lacked the plan to deliver solutions, contributing to greater public distrust.
To address the panic, the IOM released “Crossing the Quality Chasm: A New Health System for the 21st Century” in 2001, identifying six healthcare improvement aims. These included safe, timely, effective, efficient, equitable, and patient-centered care. This report highlighted the importance of quality care and called for redeveloping the healthcare system to break barriers and provide uniform care to all patients. The modern-day focus of healthcare is striving for improved health outcomes with a long way to go to overcome biases in healthcare. In 2003, the IOM published Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, which exposed the realities of discrimination in healthcare, specifically showing that race and ethnicity correlate to lower quality care outcomes (Smedley & Stith et al., 2003).
The coronavirus pandemic highlighted these disparities.
Even though the disparities in healthcare were evident long before COVID-19, the pandemic continues to shed light on the flaws of the American healthcare system. A great example was the shift from traditional in-person patient care to telehealth use which further showed inequities during the pandemic due to the digital divide and connectivity high-speed broadband internet. Unprecedented adaptation to change in the new era of technology and healthcare (the new normal). Among those left behind were Hispanics, African Americans, and populations of ethnic sub-groups who were more prone to getting infected and hospitalized from COVID-19 The lack of universal health insurance and high out-of-pocket costs meant some avoided treatment or testing (Peterson-KFF, 2022b). The issue of vaccine hesitancy due to a legacy of medical distrust, and language barrier, are evidence that more work needs to be done. Although several factors have caused lower uptake among African Americans, assorted forms of biases and historical distrust of medical institutions still linger for many.
The history of medical mistrust continues to affect marginalized groups today. Women and people of color experience bias in today’s healthcare, leading to worse health outcomes (Farrelly, 2022). Women in the United States continue to face the highest prevalence of maternal mortality rates compared to other developed countries (Farrelly, 2022). Black women are 2.5 times more likely to die from pregnancy-related causes, and a large proportion of maternal mortalities could have been prevented (Farrelly, 2022). These statistics help conceptualize the impacts of implicit bias in the medical community and how they negatively and disproportionately impact minority patients. These biases towards women in healthcare stem from neglecting women’s health concerns, which results in the undertreatment of pain.
Racial and minority communities are constantly at the forefront of not receiving equal quality care (Bridges, n.d). The American bar association states, “some people in the United States were more likely to die from cancer, heart disease, and diabetes simply because of their race or ethnicity, not just because they lack access to health care” (Bridges, n.d). Both gender and racial bias in healthcare can erode trust between patients and providers, resulting in disparities in care and worse health outcomes for marginalized groups. Racial and ethnic discrimination in healthcare reduces the quality of care for people of color and limits treatment access. The National Academy of Medicine (NAM) released a report stating that even when insurance status, income, and age are similar; racial and ethnic minorities continue to receive a lower quality of care because of the bias ingrained in the healthcare system (Bridges, n.d). To activate breaking barriers is to dismantle systematic racial biases and inequalities in healthcare, starting with training in multicultural competencies as part of provider training in medical schools, residences, practices, and communities.
More presentations with providers who look like the patients they serve in support of the Black Physicians and Health Care Network (BPHN) and their efforts to ensure that Montgomery County Maryland’s Black residents relate to culturally specific physical and mental health providers.
Krishna Patel (Towson University, School of Healthcare Management)
Alexa Finnerty (the University of Maryland, School of Public Health)
Rithik Patel (the University of Maryland, School of Public Health)
Rylie Johnson (Towson University, School of Healthcare Management)
Edited and supervised by:
Dr. Anita Mwalui. Ph.D., MPH, CWP
Adepoju, O. E., Chae, M., Ojinnaka, C. O., Shetty, S., & Angelocci, T. (2022). Utilization gaps during the COVID-19 pandemic: racial and ethnic disparities in telemedicine uptake in federally qualified health center clinics. Journal of General Internal Medicine, 37(5), 1191-1197.
Alsan, M., & Wanamaker, M. (2018). TUSKEGEE AND THE HEALTH OF BLACK MEN. The quarterly journal of economics, 133(1), 407–455. https://doi.org/10.1093/qje/qjx029
Bergeron, E. (2021). The Historical Roots of Mistrust in Science. Americanbar.org. Retrieved March 1, 2023, from https://www.americanbar.org/groups/crsj/publications/human_rights_magazine_home/the-truth-about-science/the-historical-roots-of-mistrust-in-science/
Bridges, K. M. (n.d.). Implicit Bias and Racial Disparities in Health Care. Americanbar.org. Retrieved February 28, 2023, from https://www.americanbar.org/groups/crsj/publications/human_rights_magazine_home/the-state-of-healthcare-in-the-united-states/racial-disparities-in-health-care/
Centers for Disease Control and Prevention. (2021, April 22). Research implications. https://www.cdc.gov/tuskegee/after.htm
Czubaruk, K. (2020, January 13). The Belmont Report: What is it and how does it relate to today’s clinical trials? Cancer Support Community. https://www.cancersupportcommunity.org/blog/2019/10/belmont-report-what-it-and-how-does-it-relate
Donaldson, M. (2008). An overview of To Err is Human: Re-emphasizing the message of patient safety. Agency for Healthcare Research and Quality, Chapter 3 https://www.ncbi.nlm.nih.gov/books/NBK2673/
Farrelly , J. H. (2022, February 7). For Black Women, Implicit Racial Bias in Medicine May Have Far-Reaching Effects. DOL Blog. Retrieved from https://blog.dol.gov/2022/02/07/for-black-women-implicit-racial-bias-in-medicine-may-have-far-reaching-effects
Hardy, B. L., & Logan, T. D. (2021, September). The Way Back: Assessing Economic Recovery Among Black Americans During COVID-19. Retrieved February 21, 2023, from https://www.brookings.edu/wp-content/uploads/2021/09/20210929_Hamilton_HardyLogan_TheWayBack.pdf
Institute of Medicine (US) Committee on Quality of Health Care in America. (2001). Crossing the Quality Chasm: A New Health System for the 21st Century. National Academies Press (US). https://pubmed.ncbi.nlm.nih.gov/25057539/
Maryville University. (2023). How to identify and overcome your implicit bias. https://online.maryville.edu/blog/addressing-implicit-bias/
Ndugga, N., Hill, L., Artiga, S., & Haldar, S. (2022, July 14). Latest data on covid-19 vaccinations by race/ethnicity. Retrieved February 28, 2023, from https://www.kff.org/coronavirus-covid-19/issue-brief/latest-data-on-covid-19-vaccinations-by-race-ethnicity/
Peterson-KFF Health System Tracker. (2022, November 2). Hospital resources. Retrieved February 21, 2023, from https://www.healthsystemtracker.org/indicator/quality/hospital-resources/#Total%20hospital%20beds%20per%201,000%20population,%202019%20or%20nearest%20year%C2%A0
Peterson-KFF Health System Tracker. (2022, December 22). Out-of-pocket spending. Retrieved February 21, 2023, from https://www.healthsystemtracker.org/indicator/access-affordability/out-of-pocket-spending/#Household%20out-of-pocket%20spending%20as%20a%20share%20of%20current%20health%20expenditures,%202020%20or%20nearest%20year%C2%A0
Smedley, B. D., Stith, A. Y., & Nelson, A. R. (2003). Unequal treatment: Confronting racial and ethnic disparities in health care. National Academies Press. https://pubmed.ncbi.nlm.nih.gov/25032386/
Urell, A. (2020, October 31). Tuskegee Syphilis Experiment. Equal Justice Initiative. Retrieved February 27, 2023, from https://eji.org/news/history-racial-injustice-tuskegee-syphilis-experiment/