A Conversation About Racial Inequities in Health Care With Dr Scharles Konadu
Scharles Konadu, MD, is a member of the American Board of Internal Medicine’s Gastroenterology Specialty Board.
Thank you for taking the time to have this conversation with us. It’s a pleasure to be able to speak with you regarding these important topics that are incredibly relevant in our health care system.
There has been a huge focus on racial inequities in our current health care system, brought to light by the recent COVID-19 pandemic. However, these concerns are not new. Can you give us a deep dive on the history of how systemic racism has been seeded into health care?
Dr Konadu: It is important to note that racial inequity is deeply woven into the fabric of our nation. Its involvement in health care is inhumane but not surprising based on our history. Many believe the root of scientific racism stems from the comparative view of the skulls of Black individuals and the false notion that they were smaller than those of White individuals, which researchers claimed made the case that Black people are less intelligent ─ or even subhuman.1,2
Racial inequity in health care can be traced back to the inception of slavery in the 1600s when Africans were transported to colonial America under conditions barely conducive to living, with virtually no access to medical treatment. If enslaved people were sick or died, their bodies were just tossed overboard.3
From the 1700s to the mid-1900s, well after the Civil War and the Emancipation Proclamation, without their knowledge or consent, Black men and women were the subject of unethical medical “experiments” for the advancement of knowledge and technique. This included but was not limited to the injection of smallpox being tested as a method of vaccination,4 the development of gynecologic and obstetric surgical techniques on Black women without the use of anesthesia,5 the nonconsensual use of cervical cancer cells famously pegged “HeLa cells” from a Black woman named Ms. Henrietta Lacks,6 and most notably, the Tuskegee experiment of 1932 when the US Public Health Service started a 40-year experiment on 600 Black men, primarily sharecroppers, after having them enroll under the false premise that they were getting free medical care from the federal government.7
Unfortunately, while we have made progress, racism exists in modern health care and there are many examples—Black mothers who are 2.5 times more likely to die due to peri- or post-obstetric complications than White mothers—an astonishingly high number.8,9
Black people are dying of COVID at 1.9 times the rate of White people [according to the Centers for Disease Control and Prevention], vaccine distribution centers are largely inaccessible to Black communities,11 and Black people are being turned away at a higher rate when they present with COVID symptoms.12 Recent examples that have gained media attention are that of Dr Susan Moore, who passed away from COVID 19 after being denied the necessary medical treatment despite her persistent requests, and Serena Williams, who practically begged for the proper imaging that eventually diagnosed multiple pulmonary embolisms shortly after she gave birth.
How does unconscious bias from various health care workers impact patients within our health care system? I would love to hear a bit about your personal journey through this as well.
Dr Konadu: Implicit bias impacts care to minority patients on several levels. Studies have shown that Black patients receive less aggressive care in regard to both diagnostic workups and therapeutic treatments.13 This can be explained by the uninformed perception that minority patients are uneducated or uninterested in their own care or are simply seeking to access pain medication.
When they are involved in their own care to the point where they show initiative in the request for pain medications or certain studies, they are often labeled as problematic, needy, or aggressive.14,15 Black and Hispanic people are also less likely to receive appropriate levels of analgesia in emergency department (ED) visits.16
Some cardiology studies, for example, have revealed that relative to White people, Black and Hispanic people are less likely to receive appropriate medications or undergo coronary artery bypass grafting.17 Again, these are just a few examples of the micro- and macro-aggressions Black Americans face in the health care system.
I actually carry the unique perspective of being both patient and physician. As a physician, bias comes from colleagues, staff, and patients themselves. Throughout my training and even currently in my career, I have been the target of micro-aggressions fueled by implicit bias. As a trainee and even now in independent practice, I am repeatedly confused for a nurse, physical therapist, or even the cleaning staff—anything but a physician—all while wearing my white coat!
When I underwent a C-section and gave birth to my daughter, I was told by my nurse (who was fully aware that I was a gastroenterologist) that my pain was simply from gas…and I could wait a “few more hours” for my pain medications. Though I was not naïve enough to believe this would happen to me, I will admit it was shocking and demoralizing.
This highlights what has been found in studies: that even after controlling for the variables of socioeconomic status and relative access to care, minority patients are consistently denied the basic rights to equivalent care when compared with White counterparts.
I believe the path to change needs to start with an earnest desire to understand the historical context from which racism and racial inequities were birthed, finding interventional approaches that respond directly to the needs of people of color, and implementing these approaches throughout the entire health care field in ways that are conducive to those specific communities.
Prior to the pandemic, do you think the health care system was moving in the right direction in terms of health care and access equity? If so, what do you think were the catalysts for that change?
Dr Konadu: There are efforts that cannot be ignored such as the Affordable Care Act, which I do feel has made a favorable impact. That being said, there is still a great deal of implicit bias from health care providers toward patients and their families when they are people of color.
As I stated before, racial differences in health care persist even at equivalent socioeconomic levels, and despite the overall improvement in life expectancy in the United States, life expectancy of Black Americans, in particular, has stagnated.
How and why is representation important in health care? You use social media accounts, such as Instagram, to educate women and people of color. How has that experience impacted you?
Dr Konadu: It determines the livelihood of my community. Representation was so important for me when I was choosing my career path, I honestly would not have considered a career in gastroenterology had I not seen my mentors (academically well-qualified minority women) in the positions of faculty and fellow. That kind of representation provides a safety blanket of comfort and slowly helps peel away at a looming imposter syndrome, which is bound to make its dark intermittent appearance throughout one’s career.
For this same reason, it is important for patients to see people who look like them. As a trainee, time and time again on rounds, I witnessed a person of color give blank nods when their medical condition and plan of care were explained to them.
Oftentimes, I would go back and ask if the patient understood what had just been explained. The majority of time the answer was no. This patient rapport goes beyond education, but is heavily cloaked in comfort, trust, and empathy that undoubtedly requires a sophisticated level of cultural sensitivity.
I know this is a big question, but what can we do moving forward? What seeds can be planted today to identify and overcome racial inequities in our health care system that would improve patients’ lives 1, 5, or 10 years from now on a system and on an individual level?
Dr Konadu: It is a big question, but I believe it has a simple answer. On an individual level, mandatory cultural sensitivity training is imperative in all fields of health care. In its absence, implicit bias is inevitable and will remain an anchor of health care in America and there should be a national ZERO tolerance policy for racism in the workplace.
On a systemwide level, a consensus and direct acceptance that racism is the driving force behind health disparities and inequities is of vital importance. Without taking this step, there is no moving forward.
Black patients are often undertreated for pain and some “dress up” before seeking emergency care so that health care providers won’t think they’re seeking drugs. What do you want to tell your colleagues about how people of color experience the health care system?
Dr Konadu: It is intimidating. The forced inferiority complex is an illness in its own right. On top of battling whatever underlying medical issue ails patients, they must also worry about how they’re perceived simply so they can receive basic appropriate and equitable care.
A few anecdotes: I have had family and friends call me after being sent home from the ED. My urging for them to return to the ED and ultimate discussions with ED staff has led to diagnoses such as acute pulmonary embolism and even rectal abscess. Both are reasonable causes for admission from the ED to the hospital. I constantly must serve as the “go to” advocate and assert my credentials simply so basic levels of care and attention are granted. No one should have to experience this.
You are a gastroenterologist. How have you seen COVID-19 impact your patients? What precautions are you taking for your own physical and mental health?
Dr Konadu: I am typically consulted for feeding tube placement due to the need for tracheostomy or the long-term effects of encephalopathy from prolonged intubation and sedation.
In the beginning, I will admit I was constantly hyper-anxious about potential exposure and passing the virus on to my newborn because I was breastfeeding. That fear is slowly subsiding now that the vaccine has been rolled out and appropriate personal protective equipment and other measures are given the highest priority. At the end of it all, I always consider it an honor to take care of the sick.
Tell us about your experiences in China and Ghana and your role on the West Africa Institute for Liver and Digestive Diseases (WAILD). How has this experience changed your perspective and exposure?
Dr Konadu: My times abroad gave me the sorely needed perspective of how health care is managed outside of the United States. The practice of conservative medicine is an art all on its own.
Once you are in a situation where you can only rely heavily on your inherent fund of knowledge and physical exam skills, professional and personal growth is unavoidable. What I valued most was the exposure to the rich cultures both in China and Ghana. I spent time learning about Chinese traditional medicine and West African tropical medicine, opportunities that would have been very difficult to attain in the United States.
My time in Ghana fueled my involvement with WAILD. As an institution, we offer educational, preventive, and interventional general gastrointestinal and liver services to West Africa, with a broader goal of serving as a training hub for physicians interested in gastroenterology.
It’s enlightening when you are exposed to a world outside of your own but rewarding when granted the opportunity to make an impact even in those foreign spaces.
- Titowsky K. Phrenology and “scientific racism” in the 19th century. Vassar College blog. Real Archaeology. Spring 2017. Accessed March 15, 2021.
- National Museum of African American History and Culture. Historical foundations of race. Accessed March 15, 2021.
- Library of Congress. Immigration and relocation in US history. A journey in chains. Accessed March 15, 2021.
- Brooks W. African-American contributions to medicine – part 1 of 7. University of Nebraska Medical Center. 2002. Accessed March 15, 2021.
- Villarosa L. Myths about physical racial differences were used to justify slavery – and are still believed by doctors today. The 1619 Project. NY Times Magazine. August 14, 2019. Accessed March 15, 2021.
- Skloot R. The Immortal Life of Henrietta Lacks. New York: Crown Publishers; 2010. Accessed March 15, 2021.
- Corbie-Smith G. The continuing legacy of the Tuskegee Syphilis Study: considerations for clinical investigation. Am J Med Sci. 1999;317(1):5-8. doi:10.1097/00000441-199901000-00002. Accessed March 15, 2021.
- Melillo G. Racial disparities persist in maternal morbidity, mortality and infant health. American Diabetes Association conference, June 13, 2020. Accessed March 15, 2021.
- Fernandez ME. Why black women are less likely to survive pregnancy, and what’s being done about it. American Heart Association. February 10, 2021. Accessed March 15, 2021.
- Centers for Disease Control and Prevention. COVID-19. Disparities in deaths from COVID-19. Updated December 10, 2020. Accessed March 15, 2021.
- Ndugga N, Pham O, Hill L, Artiga S, Alam R, Parker N. Latest data on COVID-19 vaccinations race/ethnicity. KFF (Kaiser Family Foundation). March 17, 2021. Accessed March 15, 2021.
- Grubbs V. The health care system has the black community in a choke hold. CHCF Blog (California Health Care Foundation). August 4, 2020. Accessed March 15, 2021.
- Bridges KM. Implicit bias and racial disparities in health care. ABA. Human Rights Magazine. 2021;43(3). Accessed March 15, 2021.
- Hoffman KM, Sophie Trawalter S, Axt JR, Oliver MN. Undertreatment of pain: racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. PNAS. 2016;113(16):4296-4301. doi:10.1073/pnas.1516047113. Accessed March 15, 2021.
- Wyatt R. Pain and ethnicity. Virtual Mentor. 2013;15(5):449-454. doi:10.1001/virtualmentor.2013.15.5.pfor1-1305. Accessed March 15, 2021.
- Lee P, Le Saux M, Siegel R,et al. Racial and ethnic disparities in the management of acute pain in US emergency departments: meta-analysis and systematic review. Am J Emerg Med. 2019;37(9):1770-1777. doi:10.1016/j.ajem.2019.06.014. Accessed March 15, 2021.
- Johnson A. Understanding why black patients have worse coronary heart disease outcomes: does the answer lie in knowing where patients seek care? J Am Heart Assoc. 2019;8(23):e014706. doi:10.1161/JAHA.119.014706. Accessed March 15, 2021.