Howard Ross, founder of Cook Ross and author of several publications on diversity and bias, was the final presenter before the workshop’s concluding discussion. He used the COVID-19 crisis to illuminate the impact of systemic bias, pointing to the large difference in mortality rates between whites and African Americans from the disease. He identified five major factors that underlie this gap: socioeconomic factors; health disparities; bias,
assumptions, and structural racism; everyday logistics; and psychological impacts. “What I want to weave here is a tapestry that a lot of seemingly disconnected factors play a dramatic role in the numbers related to the Black-white disparity in mortality rates related to COVID-19,” he said.
As noted earlier in the workshop, African Americans have 7 percent the acquired wealth of white households, making for less of a nest egg to fall back on. African Americans also have a lower percentage of salaried versus hourly jobs, and Black unemployment (even before COVID-19) was roughly twice as high as white unemployment. Roughly one in six Black and Hispanic households spend more than 50 percent of their income on housing. The impact is a greater incentive to work, less economic reserves, and less access to food, as well as less access to medical support and funds to buy personal protective equipment like masks and gloves. African Americans also have a higher percentage of “essential” jobs that bring higher exposure to the coronavirus to themselves and their families.
Statistics compiled by the Centers for Disease Control and Prevention present data that show gaps in health between African American and white populations in the United States.1 Mr. Ross reported that these data show that African Americas are 50 percent more likely to suffer from high blood pressure, 65 percent more likely to suffer from diabetes, 75 percent more likely to have a stroke, 50 percent more likely to have some form of cardiovascular disease, and 60 percent more likely to suffer from childhood asthma. African Americans also have more than twice the infant mortality rate and have significantly more cases of HIV infection. According to data that Mr. Ross cited from a Georgetown University study, African Americans in Washington, DC, are 3.5 times more likely to live below the poverty level and also are more likely to suffer or die from a number of health conditions (Georgetown University School of Nursing & Health Studies, 2016). These
conditions, in addition to health disparities brought on by such environmental problems as climate change and exposure to pollutants and toxins, are co-morbidities that are directly impacted by and make people more vulnerable to COVID-19, Mr. Ross said.
Biases, Assumptions, and Structural Racism
Historical narratives about race have created structural arrangements (e.g., where people live and work) and differential treatment that create a dominant/non-dominant relationship between whites and people of color, especially African Americans, Mr. Ross stated. He noted these structures and systems were built many years ago, and they have evolved, and often devolved, over time. He stated:
One of the challenges we have is that so much of it [inequality] is what we call our “normal” existence that many people do not question or challenge it. We see people in circumstances and rather than judge the circumstance they are in, those in the dominant community tend to judge the people in the circumstance…. The victim becomes seen as the cause of their own victimization.
Policies and practices reinforce the narrative, and unconscious bias impacts African Americans in many ways, especially in health care, he said, referring to several studies to illustrate his points. An empirical analysis of racial differences in police use of force (Fryer, 2016, 2018) showed that white police officers were more likely to use violence against Black compared with white members of the public. These actions, he said, are tied to “who looks dangerous” to a police officer and can be visceral, fast-brained reactions. Connected with the COVID-19 crisis, he pointed to a disproportionate number of African American men in prison, where social distancing and other preventative health measures are difficult to implement.
Other research points to implicit bias in the provision of health care. For example, a study revealed how implicit bias among physicians can predict their thrombolysis decisions (related to procedures to treat blood clots) for their Black and white patients (Green et al., 2007). A literature review published in the American Journal of Public Health (Hall et al., 2015) showed implicit racial/ethnic bias among health care professionals in 14 out of the 15 studies under review. Thus, he said:
We are not talking about something that happens every once in a while, where you happen to have an errant person…. We are talking about a system producing this result time after time.
Related to higher education, Mr. Ross described a study in which researchers pretending to be students sent emails to 6,500 professors in 89 disciplines at the top 259 schools in the country (Milkman, Akinola, and Chugh, 2015). The names of the students were chosen to express gender and ethnicity. The emails signed with what seemed like white male names were 25 percent more likely to receive a response from a professor, with the percentage rising among professors at the highest-rated schools and in higher salaried subjects. Ross said:
Responsiveness from your professor, the ability to get communication, to get information, to get your questions answered—when the professor says, ‘I have an open door policy,’ is it really open to everybody? All of these are factors which impact students’ ability to be successful and contribute to the relationships that get built that are so important. And it’s also important for us to recognize that these mentoring relationships, these sponsorship relationships tend to be much more important for people in non-dominant groups than in dominant groups.
A study of the membership in the Alpha Omega Alpha Honor Society showed that students of color were significantly less likely to be chosen as members, even when controlling for other factors: Blacks were less than 20 percent as likely as white students to become accepted into these societies, Asians were 50 percent as likely, and Latinx students were 79 percent as likely (Boatright et al., 2017). Many medical school programs use these memberships as a formal or informal criterion for acceptance, Mr. Ross pointed out.
These issues regularly happen across society, he continued, but fear, such as that surrounding COVID-19, exacerbates the impact. The collective human mind undergoes what Daniel Goleman has called an “amygdala hijacking.” When in extreme trauma, this “fear center” part of the brain takes over, which can result in reactive responses (fight, flight, or freeze); protective responses (desire for control, a turn toward authoritarianism, or increased “otherization”); and narrowed thinking and interpretations (preventing a more collective response).
Many difficult everyday logistics disproportionally impact African American communities, Mr. Ross stated. These factors include accessibility to transportation, health care, and safe markets and commercial spaces; lower levels of health insurance; higher levels of pollution; lack of green spaces and recreational facilities; closer physical proximity; and lack of trust in law enforcement.
These factors taken together create a psychological impact that has health implications, as shown with COVID-19. Mr. Ross referred to psychological safety, with feelings of increased stress and vulnerability; questionable trust in government; limited access to information; less trust in medical research; learned helplessness; and “otherization” and perceptual safety. He quoted an African American man, writing in the Guardian newspaper, who expressed fear about wearing a face mask while going to the grocery store despite the public health guidance to do so (Thomas, 2020). As he wrote, “my voice of self-protection reminded me that I, a Black man, cannot walk into a store with a bandanna covering the greater part of my face if I also expect to walk out of that store.… For me, the fear of being mistaken for an armed robber or assailant is greater than the fear of COVID-19.”
Mr. Ross agreed with previous presenters that the systemic impact of racism requires systemic change. An example of a systemic change relates to the gender composition of major symphony orchestras. Orchestras were 5 percent women in 1970 and 12 percent women in 1980. When changes were made—such as openly announcing auditions and conducting them behind a screen so the evaluators would hear the quality of the music but not see the person performing—the numbers rose to more than 40 percent.
Changing systems requires thinking from a systems perspective, he said. Moreover, he added, without this systemic view, individual actions may have a negative long-term effect. He urged interventions in four domains to create systems that are less biased: education, priming, systems and structures, and accountability.
In terms of education, Mr. Ross acknowledged disagreements about whether training to reduce or eliminate unconscious bias is effective but asserted that bias awareness training can work. One study showed that this type of training can help medical professionals “learn about unconscious processes that provide them with skills that reduce bias when they interact with minority group patients,” he said, quoting from a study by Stone and Moskowitz (2011).
Priming refers to follow-up after training that can help people “at the moment it is needed,” he explained. For example, a person on a selection committee can participate in bias awareness training but not use the information for several months. Showing a short video or providing a series of questions based on the training right before going into a selection committee meeting increases the impact of the training, he said. Related to this concept is “nudging” to embed certain behaviors. The example he provided is when people “opt out” of designating they would like to be an organ donor versus “opting in.” Looking at European countries, the opting-out system results in near-universal organ donor designation, while the opting-in system results in far lower participation. Mr. Ross particularly called out the impact of a nudge when looking at two countries with similar cultures: Austria (99.98 percent organ donors with an opt-out policy) compared to neighboring Germany (12 percent with an opt-in policy). Related to COVID-19, priming and nudging examples include signs that show where to stand to keep the recommended distance from others. More broadly, there are things that can be built into systems to remind people on a daily basis about what they are supposed to be doing.
Looking at aligning structures and systems, Mr. Ross focused on the workplace, such as removing names from the initial screening of resumes, checking interview questions for bias, using diverse panels for hiring, and conducting fair performance reviews. “In every area of talent management, we can find ways that bias impacts us,” he said. “None of these individually is going to change the system, but the collection of all of them has a huge impact on the system.”
The fourth domain is accountability. In looking at the many parts of a system, he stressed the need for metrics to determine if differential impacts are occurring related an organization’s history, values, and the environment.
Harriet Washington referred to the work of social psychologist Mark Schaller, who has proposed that protective prejudice and heightened degrees of xenophobia come into play during a crisis, which totalitarian regimes can capitalize on. Mr. Ross agreed with this theory, as shown with excessive otherization. Both otherization and production of empathy can now be detected in images of the brain.
Another participant asked how to counter the claims of some powerful whites that people of color are genetically inferior as a scapegoat to acknowledge implicit bias. Mr. Ross stated it is the primary responsibility of the white community, not just people of color, to raise awareness and correct this claim. Those in the dominant group, he said, often do not pay attention to their own privilege and entitlement. Social structure also reinforces this, with some people believing that “if there is someone below me, I feel better.”
Dr. Jones referred to her keynote address (see Chapter 2), in which she pointed out that one of the impacts of racism is to sap the strength of the whole society. She asked Mr. Ross and the entire group how to better communicate that “racism is for real and is sapping the strength of the whole society through the wasting of human resources.” Mr. Ross responded, “We will have no solution to these problems until we see them as collective, societal problems and not the problems of individual groups. This is one reason why our ability to establish the business case, the financial case, the economic case, the performance-based case for everyone’s full participation is so important.”
Mr. Ross said he uses a business-case approach in diversity, equity, and inclusion (DEI) work with organizations, in addition stating moral convictions. “I know some people are sick and tired of building the business case,” he acknowledged, “but it’s amazing how many people still don’t get it, and also how it continues to evolve.” As the nation’s demographic composition changes, he added, it becomes easier to make that case with leaders, stressing the impact on “your business, your hospital, your patient outcomes, turnover.” While he suggested speaking to “the goodness in people about the importance of diversity, we have to deal with reality, and go in where the door is open.” He said a business case can be found in almost all situations, although sometime requires some digging.
Ms. Washington pointed out that in the medical sphere, medical interdependence and the intersection of risk is often a compelling argument to
find ways to reduce disparities. Environmental toxins have been shown to affect mental capacity as measured by IQ scores, predominately in communities of color but also the nation as a whole, she added, while noting the debate about what IQ tests truly measure.
Turning to assimilation, Dr. Bright observed that the minority culture is usually expected to change to adapt to the dominant culture and asked how that can change. Mr. Ross observed that most people in the dominant culture are so used to this, they do not see that assimilation has even taken place. Environments are needed to explore other cultures without cultural appropriation, he said.
In terms of increasing the number of Black men and Black women in medicine, Dr. Jones suggested a strategy for medical school committees to “burst through their bubbles of experience” by creating opportunities to experience common humanity in different settings and join together in common cause. Related to residential segregation, she said, “the most profound damage is that the walls are so tall and yet invisible—people don’t even know there is another reality.” Examples suggested including pairing science classes from different schools to work on a common project, a multicultural Passover Seder, and a series of “equitable dinners” in Atlanta, Georgia. Regular organizational activities, such as setting up mixed culture teams on projects or book clubs, were also cited as examples.
Health disparities have an economic cost as well. David Acosta elaborated on what he termed the cost effectiveness of health disparity work and its long-term value. Diversity officers and others can show that a diverse workforce improves health outcomes and saves money through working with the community, reducing hospital re-admittance, and increasing health literacy, decreasing the number missed appointments, or reducing errors from not understanding health-related instructions. Dr. Jones urged mobilizing to address the seven barriers to the achievement of health equity (see Chapter 2) as values targets, along with tackling structural targets such as residential segregation, to develop a more complete approach to an anti-racism agenda.
The session ended with a discussion of impacts on African Americans with higher income levels. In addition to the historical reasons discussed, many may experience a wealth gap because of societal expectations, suggested one participant. Cato Laurencin referred to two studies: one that showed that the son of a Black millionaire and the son of a white single mother earning less than $36,000 a year have statistically the same chance of becoming incarcerated. Another study measured the allostatic load among
African Americans, regardless of income level, incurred through such daily activities as driving with an increased likelihood of being stopped by a police officer.
A participant asked about countering anti-affirmative action efforts in medical schools. Dr. Acosta said much can be learned from institutions, such as University of Washington, University of California, and University of Michigan, that have gone through the process (see also Chapter 5). It is important to develop the documentation to interpret the law correctly and not over-interpret the laws.
Boatright, D., D. Ross, P. O’Connor, et al. 2017. Racial disparities in medical student membership in the Alpha Omega Alpha Honor Society. JAMA Internal Medicine, 177(5), 659–665. DOI: 10.1001/jamainternmed.2016.9623.
Fryer, R. G., Jr. 2016, Revised 2018. An Empirical Analysis of Racial Differences in Police Use of Force. Working Paper 22399, National Bureau of Economic Research. http://www.nber.org/papers/w22399.
Georgetown University School of Nursing & Health Studies. 2016. The Health of the African American Community in the District of Columbia; Disparities and Recommendations. Prepared for the D.C. Commission on African American Affairs. https://www.abfe.org/wp-content/uploads/2016/11/The-Health-of-the-African-American-Community-in-the-District-of-Columbia.pdf.
Green, A. R. et al. 2007. Implicit bias among physicians and its prediction of thrombolysis decisions for Black and white patients. Journal of Internal Medicine, 22(9), 1231–1238. doi: 10.1007/s11606-007-0258-5.
Hall, W. J. et al. 2015. Implicit racial/ethnic bias among health care professionals and its influence on health care outcomes: a systematic review. American Journal of Public Health, 105(12), e60–e76.
Milkman, K. L., M. Akinola, and D. Chugh. 2015. What happens before? A field experiment exploring how pay and representation differentially shape bias on the pathway into organizations. Journal of Applied Psychology, 100(6), 1678–1712. https://doi.org/10.1037/apl0000022.
Stone, J., and G. Moskowitz. 2011. Non-conscious bias in medical decision making: What can be done to reduce it? Medical Education 45(8), 768–776. doi: 10.1111/j.1365-2923.2011.04026.x.
Thomas, A. 2020, April 7. I’m a Black man in America. Entering a shop with a face mask may get me killed. The Guardian. https://www.theguardian.com/commentisfree/2020/apr/07/black-men-coronavirus-masks-safety.
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