Approaches to Curing Racial, Ethnic Inequality in Health Care

COVID-19 spotlighted some deep-rooted systemic problems in health care. The underfunding and lack of proper infection and prevention methods at long-term care facilities, for instance. The pandemic also brought to the fore inequities in access to health care. Many racial and ethnic minority groups are more at risk of getting sick and dying from COVID-19 than whites, according to the Centers for Disease Control and Prevention (CDC). Now, they are less likely to get the COVID-19 vaccines. These problems in part point to the social determinants of health (SDOH), says G. Rumay Alexander, EdD, RN. Alexander is a clinical professor in mursing at the University of North Carolina–Chapel Hill. She is also the American Nurses Association scholar-in-residence working with the Commission Addressing Racism in Nursing. Alexander was one of the speakers this week at the Global Surgical Conference & Expo hosted by the Association of periOperative Registered Nurses (AORN), where she talked about SDOH. She recently sat down with Infection Control Today® (ICT®) for a wide-ranging discussion about health care inequalities and how infection preventionists and operating room nurses can deal with that problem. “There’s a lot going on with people when they’re in environments where they’re not able to have the basics, where they’re not able to flourish, where they’re not in a healthy space to live, work, play, worship,” she tells ICT®. This doctor of education touts the benefits of always being willing and able to learn. “You want to maximize curiosity and minimize certainty. Curiosity means you ask questions, you don’t assume.”

Infection Control Today®: How do you define the social determinants of health? How would an operating room nurse or an infection preventionist apply that in their everyday jobs?

G. Rumay Alexander, EdD, RN: Really great question. Actually, social determinants of health have been a part of public health and community health curriculums and conversations and dialogue of for many, many, many, many decades. It seems that all of a sudden now it’s just surfacing in a very visible way, probably because COVID-19 really gave it a light. COVID-19 just actually pulled the curtain back and brought to the surface inequities of care, inequities in access to health care, inequities in the ability to communicate with different populations. So social determinants of health care is really about the principle, 1, that individuals have places where they live, work, play, and observe religious values. Quite frankly, if we don’t understand that, we don’t understand our patients. And so, at the end of the day, the goal is for health equity. If you think about it, there are 2 places where people don’t forgive thoughts or behaviors that treat them inequitably because [those places] proclaim themselves to be places free of bias, places

G. Rumay Alexander, EdD, RN

that really focus on what I would call a level playing field in relationship to how they’re seen, how they’re treated, how they’re perceived. And those 2 places are in health care and the other 1 is in religious institutions. We’re a bit more unforgiving when those 2 places don’t live up to what they say they are about. And that it doesn’t matter what you look like; it doesn’t matter about your race or your gender or your economic status. So social determinants of health are around the environments that people live in that are basically man-made, or human-made, situations. They come out of systems that set people up for either an equitable form of care or an inequitable form of care. And so, if you think about it, it’s like a pathogen, but it’s a pathogen, not as in the microscope, and a virus, or bacteria, but it’s in the air, it’s in the ethos. Quite frankly, we’re all products of our environment. So where we live and where we worship, and where we play matter. About 80% of health outcomes are related to the physical environment, the social determinants, and behavioral factors. Only 20% of a person’s health and well-being is related to access and quality of care. As people who are providing people care—we must understand them. And in order to do that, you have to really understand how social determinants play into the whole matter of thinking. You’re thinking about things like socioeconomic factors. You’re thinking whether there’s education or job status or family supports or community or income. You could be thinking about health behaviors like tobacco use, or diet and exercise, or alcohol use, or sexual activity. And then there’s the whole access to care piece, economically. “I can’t afford health insurance,” right? Then what’s done for me, or not done for me, is based on whether I can pay for it or not. That. As health providers, we’re responsible for understanding the whole being of a person. We’re literally going to be giving postsurgical instructions, discharge planning. We’re going to give preadmission instructions. If we can’t communicate with the patient, then now we’ve created what I call a moral insult that says that you don’t value me as a human, and therefore that affects my trust. Now my stress level is up. I’m not in my best place for surgery because these things are playing out in physical ways in my body. This is important work. This is also about…we’re on interprofessional teams now. Professions have their own cultures. They’re different, even though we’re all under the health care umbrella, right? Physicians are socialized to come toward the patient in a certain way. Nurses, another. Anesthesiologists would be another. The point is, if you think about culture as the way we do the things you do—to quote the Temptations, and I know that’s aging me, but they’re great philosophers…they say it best. Culture is how we do what we do, the way we do the things we do. That’s about decision-making. That’s about policy development. That’s about how we approach individuals. This is all a part of understanding the determinants of health. What determines good health? What determines the best outcomes? How to get the optimal health outcome for a patient. It’s proper for an organization to really help its members understand the environment that people live in but also who we’re working with. And when we’re not communicating, or we’re misunderstanding each other, or when racism or supremacy eats into our relationships, people shut down and stop talking to each other as professionals, because we’re all human, right? And all of us want to be respected. None of us wants to be insulted. Once health care providers aren’t talking to each other, the patient is really at risk and danger. You can see how this permeates the operating room, the larger health care organization itself—the hospital or the surgery center, where people are—and it messes with our relationships and our ability to come together for the good of the patient, which is why we’re all in the business we’re in.

ICT®: Do you see concern about the social determinants of health care forcing hospitals into a more activist role in communities?

Alexander: There’s what I call the business of health. And then there’s the business of health care. Now, the business of health care says you need to understand your market share. You need to understand who it is in your community that has access to your service. And you want to be culturally appropriate and culturally relevant to that market share. Because these are the people who are going to be coming in. And they need to have great customer satisfaction so that they can recommend that other people come. Or when they need to—and hopefully, they won’t have to do that often—but when they do, they need to know they’re coming into a respectful place and a place that understands them. “They get me.” [An institution] that knows about my cultural tendencies. Now, that’s not to mean generalization, as [when some might] say all Hispanics are Catholic, or all people of 1 group is biased, and another group is not. In fact, that’s an interesting thing that I just said, because we all have our biases. It has no color. That issue in itself, understanding your own biases, which play into who we’re willing to care for, and how we’re willing to care for them. And so, yes, this pushes you into understanding your community, and having community responsibilities around understanding those individuals, so that you can be in the business of health. The two go together. One should not supersede the other. It’s not about the inhumane piece. It’s about the humane piece as well. One of my mottos is “all encounters are cultural encounters.” You’re never in a place where you’re not having a cultural encounter. And people come not only with their bodies, but with their experiences of people who are surrounding them for the care. When experience shows up, it speaks, and it speaks loudly. It usually shows up as a feeling, or a thought, or a belief, or a decision about who’s worthy of getting the best care, or the minimum amount. And that’s tied to many other factors that come into play. We live in a society now that’s going to be more and more diverse. And, in fact, the numbers have been predicted for quite some time. And there’s a shift going on right now in who’s majority, who’s minority. And that matters. Because as the majority typically is making decisions, it’s making decisions [based on] its own value systems, its own beliefs, its own experiences. And unless by design, you work on understanding those who are not of the majority, you’re going to do harm. We’re in the business, and we take the oath to do no harm. We’re responsible for understanding everyone, not just the majority, and we’re responsible for serving everyone to the best of our ability. And this is why understanding those social determinants and what people have the agency to do or not [is so important]. Because at the end of the day, it’s the systems that set people up for the conditions they live in. You need to understand that full array. It’s not that they’re just lazy people, or they’re just not [intelligent] people. They’re often held hostage in situations that they did not themselves decide to live in. The decision to put the toxic waste dump in a certain neighborhood, or to put lead in the water like they did in Flint, Michigan, and intentionally give it to certain populations knowing that it would harm and not giving it to others, because we value them more. All of that’s tied into the social determinants of health.

ICT®: What part does trust play in this? If I’m a Native American and the government says to me, “Hey, we’ve got a vaccine for you. Do you want to come and get it?” I might have second thoughts about that. How do you deal with that?Alexander: Trust is a huge, huge piece. You just went back to the experience that Native Americans have had when they trusted the system, and they expected it to be thoughtful about them, caring about them, and having their best interests at heart. And they can point to times when that wasn’t true. The same is true with African Americans and the Tuskegee experiment where trust was an issue. We’re living right now dealing with trust issues. In order to be trusted, you have to be trustworthy. Trustworthy means that you do what you say you’re going to do. This is why I made that comment earlier about the people not forgiving institutions who proclaim that “we treat everybody with the best of intentions to the best of our ability,” when [those groups have] had an experience that’s different. Nurses are the most trusted profession in the country, of all the professions, and have been for the last 18, 19, 20 years. And so when we are a part of a system that is not giving that kind of thought to who it is we’re caring for, and we’re making differences in how we treat them, and we as nurses don’t advocate for the patient, or speak to those issues—or any health provider—then we have created this distrust which we pay for down the line like we’re doing with the vaccine distribution. They’re not isolated events. Experiences aren’t isolated events. The narratives that get passed [down] generationally about how someone like us from a certain identity group are treated impacts the future about what people are willing to do, where they’re willing to go, what they might even consider to be honest information. Now we’ve got this vaccine hesitancy for reasons that really date back to…one of the reasons obviously, there are some myths out there that aren’t true...but one of the reasons is our historic memory. We haven’t always been valued. In fact, some of us have been treated very inhumanely, or dehumanized is another way of thinking about it. Once you dehumanize someone, you can do anything to them. So why would I place myself in your hands if I don’t trust you? There’s a power inequity there. If I’m unconscious on the table, and you’re in charge, I’ve turned over my agency and my power to you. Something that valuable—be it my child, my wife or husband, my grandmother, my mother, my father or grandfather, people who are precious to me—if I turn that over to you, and I’m vulnerable at that point, then I need to be assured. I need to be able to trust that you’ve got my best interest at heart. And so that’s going to take decades because trust is something that you build. You can destroy it in seconds. And then it takes you years again to build it. And what we’re talking about now are decades of places where people can point to when you didn’t have my best interest at heart for reasons other than thinking of me as human. We’re kind of in that rehumanizing phase and rehumanizing is part of gaining that trust back. But rehumanizing is also part of the social determinants. They all come full circle. A bad decision can have really long-term consequences. And I’ll tell you something that I use often that sounds like a health care statement, but it’s more of a parenting statement. And quite frankly, it’s something that my mother used to tell us—me and my two sisters as children—but it works even in work settings. And that is: “You can’t talk your way out of what you behaved your way into.” That kind of wraps up what I mean, by the trust factor: You’re saying one thing; you’re doing another.

ICT®: The two groups who least want to get the COVID-19 vaccine are African Americans and Republican males. It’s strange how this lack of trust can manifest itself in such different groups.

Alexander: Trust is a very human factor, just like empathy is. And you were talking a minute ago about putting yourself in someone else’s place. Part of the ability to be culturally appropriate and relevant is that ability to have empathy for others, to put yourself in their shoes. If I lived where they lived, and if I were born at the time they were born, would I be different? How would I feel? “Here I am. I made it. I don’t know why you can’t make it.” One of the things that is really tied to this whole social determinants piece—and notice it’s social, meaning man-made—is what’s called deaths of despair. There are about 20 million Americans experiencing what is called a demographic depression. And most of them are relatively young, they’re predominantly White, less than college-educated, and have not benefited from economic growth, or they’ve lacked access to care, they’ve suffered from debilitating pain on a daily basis, usually due to some form of disability, which is often observed in later life. But there’s this—with these groups, as I said, it’s predominantly White, but it’s also populated by all the other racial and ethnic groups as well—[there’s] a higher rate of death. And the researchers refer to it as deaths of despair: suicides and alcohol- and drug-induced deaths. And that has contributed to a decline in life expectancy by 3 to 4 years. There’s a lot going on with people when they’re in environments where they’re not able to have the basics, where they’re not able to flourish, where they’re not in a healthy space to live, work, play, worship. It’s an important piece for us to understand, and if trust isn’t there, and I am someone who is self-medicating to cope with my despair, and I don’t trust that you will understand that so I don’t tell you in the patient history, you [the provider] could have an outcome that you can’t explain. Or you could be administering something or doing something that normally you wouldn’t, and have an adverse outcome. But because they didn’t trust you and you were missing that piece of information which was vital, you now have a bad outcome. That bad outcome could lead to being in intensive care. If that person doesn’t have insurance, the cost of care goes up because they don’t have the coverage. My point is 1 feeds the other. The healthier we are as a whole of people, the more the systems are healthy as a whole.

ICT®: Is there something that I neglected to ask that you think is pertinent to this conversation that you want your fellow health care professionals to know?

Alexander: The main thing is we have to remember that we’re in the business of patient care. And we need to be patient-centered in all of our thinking. We should really give some thought to how our decisions are being made. We need to really work on self-awareness. And that’s an important piece, understanding what pushes your buttons, asking yourself questions about “Why do I think this?” about this individual or not. And like I said, we all have biases, most of them are invisible, but they’re operating—unconscious bias or implicit bias. The more you know what your biases are and you’re working on them by design, you’re going to give better care. You’re going to naturally start working on “How can I be the best health care provider for this person who’s in their most vulnerable state, and has turned their life, or the life of their precious one, [over] to me?” Which is a space that’s sacred, and it’s a space that not everybody gets exposed to. If we’ll just think about ourselves, or think about our mind, like a computer with a “maximize” and “minimize” button: You want to maximize curiosity and minimize certainty. Curiosity means you ask questions; you don’t assume. Curiosity means you go learn things. That you come to an honest place of saying, “Here’s what I don’t know.” Because that’s what true education is about. Getting to know what you don’t know and learning it—filling in that void. I think when we do those things, we’re bringing our best selves. And we’re meeting our obligation to our patients. And I think that’s where I’ll leave it.

This interview has been edited for clarity and length.