Why do Black Americans experience health disparities?

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We spoke with the assistant dean for diversity and inclusion at the College of Dentistry to discuss health disparities faced by Black Americans, why the Black community has historical mistrust of health professionals, and ways we can evaluate our own innate biases so we can improve our outlook and treatment of people who are different from us.

Episode Transcript

Lindsey Hendrix: We bring you advice and compelling insight on the latest in health, medicine, and scientific discovery from tips for getting better sleep to discussions about major issues like health disparities in America, we’ll talk about it. You’re listening to Texas A&M Health Talk, part of the Texas A&M podcast network.

Hello and welcome to Texas A&M Health Talk. I’m your host Lindsey Hendrix. We’re going to continue the discussion about health disparities in America. Last episode we dove into disparities faced by the LGBTIQ+ community and we talked about ways that Texas A&M Health is trying to better prepare future health professionals to care for LGBTIQ+ patients. If you haven’t listened to that one, go back and listen to the last episode we published.

Lindsey H.: In today’s episode we’re going to talk about health disparities related to race, specifically, disparities faced by Black Americans. To help me with this interview, I have asked my coworker and friend, Dee Dee Grays to join me as a co-host. Hey, Dee Dee.

Dee Dee G.: Hey, Lindsey. So excited to be here today, not only to talk about this topic but also I’m excited being your first co-host. Woohoo.

Lindsey H.: Yay. I know. I’ve been talking to Dee Dee about this behind the scenes a lot. I have promised her that she would come on as a co-host and I just feel like this topic really needed Dee Dee’s perspective. I can’t talk about this from a personal perspective but Dee Dee does bring some insight. She had an experience with her sister. I know that she’s experienced some stuff with her family. Thank you so much.

Dee Dee G.: No. I’m grateful to be here for this conversation. I think that especially Black Americans run into this issue a lot and if you don’t have a personal experience, either a family member or a friend has this experience, and so I think it’s very important that we all talk about it so that we can find solutions on how can we make it better? How can we make the health care system better to where we don’t have these problems when someone of color does have to visit a doctor or have any kind of medical issue?

Lindsey H.: Yeah. How great was Dr. Holyfield? I think she brings so much wisdom into this issue. She’s done so much amazing work at the College of Dentistry.

Dee Dee G.: No, I agree with you. She has a load of experience and a lot of knowledge that she can share on this and the work that she’s doing at the College of Dentistry is awesome in helping students understand what health disparities are out there and how they can kind of fight these biases that they have that they may not even realize that they have.

Lindsey H.: Yeah. I thought that was a really good point that she made is that we really need to do the work to help identify what innate biases we might have that we’re not even aware of. What’s really cool is after we recorded this episode, the College of Dentistry was announced as a 2020 HEED Award Winner from INSIGHT Into Diversity magazine, which is really awesome. HEED stands for Health Professions Higher Education, Excellence in Diversity. That is one of the most prestigious awards that institutes of higher education can get for their work in diversity. Congrats to the College of Dentistry for that.

Dee Dee G.: Yes. Very much so. Congratulations, College of Dentistry.

Lindsey H.: Yeah. Well, without further ado, let’s get into the episode. Yay. Dee Dee, as our first guest host on Health Talk, which I hope you’re as excited about that as I am, would you do us the honor of introducing today’s guest?

Dee Dee G.: I would love to. Our guest today is Dr. Lavern Holyfield. Dr. Holyfield is the assistant dean for diversity and faculty development at the Texas A&M College of Dentistry. Welcome, Dr. Holyfield.

Lavern Holyfield: Thank you.

Lindsey H.: Thank you so much for being here, Dr. Holyfield. Let’s go ahead and dive right on into this topic. We’ve got a lot to cover. Let’s get started. First of all, let’s set the stage with some facts. What does the data tell us about health disparities related to race and ethnicity in America?

Dr. Holyfield: Well, when compared to mainstream population, minority populations bear a significantly higher burden for disease, poor quality health, and less than optimal health outcomes. The United States ranks lower than most peer nations on infant mortality, age-adjusted death rates, life expectancy and others and racial and ethnic disparities exist in quality and in length of life among U.S. residents.

For any particular disease, you will find that ethnic minorities actually have a higher rate or higher incidents of problems related to health care and overall health outcomes. For instance, African Americans have a greater incidence of liver and stomach cancer. In terms of oral health, African American males are more likely to die from oral cancer than any other population. It’s mostly because of their race and their ethnicity. When you rule out differences such as socioeconomic status, access to care, and try to put them on an equal footing that still doesn’t help. The disparities continue to persist.

Lindsey H.: What got you interested in addressing this issue? I know you’ve done a lot of work at the College of Dentistry. You’ve been working on this issue at the Health Science Center for quite some time. What inspired you to start addressing this?

Dr. Holyfield: Well, for obvious reasons, I am an African American, and when I learned that people who look like me are having disparities in health care and health outcomes it piqued my concern. I started teaching cultural competence and the purpose for that was to help make sure our students understood that they needed to be sensitive to the needs and preferences and health seeking behaviors of all people, not just folk who looked like them.

In doing that, I started to look more and more into health disparities and what really concerns me is the fact that when everything else is on an even playing field there are still disparities among African Americans and other minority populations. It just became a passion of mine to do everything that I could in terms of educating our students, our future health care providers, about the things that they needed to do to try and help overcome this situation.

Dee Dee G.: Why do you feel that especially in the medical field there is this… especially when it comes to African Americans more so on different biases? I know there was a study that came out several years ago where med students were surveyed and they were saying that they still believe that African Americans had a higher pain tolerance or they thought that their skin was a little bit thicker. Where do these notions come from?

Dr. Holyfield: Well, these are all steeped in racism and discrimination, these beliefs and a lack of education and a lack of the desire to educate for people to understand that these things are myths and they are not true. When you look at the way African Americans, in particular, are viewed, we’re viewed as less than human by many folk within this country.

When you don’t give a person their humanity, you don’t care about what’s wrong or what’s happening with them so you don’t want to study, you don’t want to find out any differences or anything that needs to be corrected because it doesn’t matter, they’re not human anyway. It’s that racism and that discrimination that is the root of the problem.

Dee Dee G.: I know that there are many I think, especially in the African American community and even in other minority communities, where they have stories of where they’ve gone to the doctor and the doctor didn’t believe they were having these symptoms or they felt that they were over-exaggerating or, in my instance, my sister had some issues and one nurse actually changed her pain medication over what the doctor said because she didn’t think she needed it. It’s amazing how many people you know have … If it’s not personal to them, it’s happened to someone they know.

Dr. Holyfield: A lot of times stereotypes come into play rather than taking the time to individuate, to learn and understand what’s happening with one individual. Health care providers tend to look at the group and that means that they’re overlooking something in that particular individual. A lot of this can be traced back to implicit bias. They don’t intend to be biased, and in fact, if you ask a health care professional, I’ll bet you that the majority will say, “Oh, no. I’m not biased” but bias is innate.

Implicit bias they may or may not even be aware of. What we teach our students is to learn your biases, learn about yourself, think about those things that you’ve been taught or that you’ve observed or learned about other groups but remember that what happens for a group or within a group does not necessarily mean that it’s for that individual that’s presenting to you. If we can get everyone to think like that, I think we will have a good hold on solving this issue.

Lindsey H.: I know you as an educator and a lot of the faculty that you work with at the College of Dentistry are working to combat some of these implicit biases that you just described. What are some of the specific measures that you’re taking with dental students at the Texas A&M College of Dentistry?

Dr. Holyfield:

We have embedded throughout our entire curriculum for dental hygiene students, for every pre-doctoral or dental student and for our graduate student in residences, training in cultural competence, in cultural sensitivity, where we actually take them through scenarios. We help them to understand the importance of being not racially blind, no, but paying attention to the race because race can make a difference in the way things work for people but to treat every patient individually based upon their specific needs.

We look at cultural and racial preferences and things of that nature as a starting point and we build from there. Throughout the curriculum, we have different coursework that helps to build … From the very beginning, it builds up until they finish their matriculation. Students in their third and fourth year have to report to us a culturally related experience, an experience for a patient who’s culturally different from them in any way. It could be age, gender, ethnicity, race, any difference, and what they did to overcome those challenges that those different experiences presented. In that way, I understand a perspective one patient at a time, how it has affected or had an impact across the board in terms of clinics, that’s something that we need to really look into.

Dee Dee G.: Do you feel that, especially as the younger generations are coming in, do you feel that they’re not as complicit with some of these biases or that they seem to have a greater understanding and not so much as the older generation has?

Dr. Holyfield: I think they’re more accepting because they have been in diverse situations most of their lives. They may hear about some of the disparities and be completely surprised and many of them will say, “Well, that’s not going to happen on my watch because I’m not that way.” We urge them to understand that this is innate and they need to do everything they can to recognize where there may be a bias, where there may be a stereotype that affects what they’re doing but I would think that for the most part, and I guess I can say for the most part, I can see some differences.

We’re getting less pushback when we teach these subjects than we did before. I can look at course evaluations and see they’re not quite as angry with me when I talk to them about these differences and the problems as they were five, 10 years ago.

Dee Dee G.: It’s a sensitive subject and I think sometimes you’re having to push into subjects that a lot of people just don’t like talking about. I can see where those surveys are probably like, “Okay, these are interesting.”

Dr. Holyfield: Yes. Yes.

Lindsey H.: Yeah. I mean, you’ve got students coming into the dental school in Dallas from communities all over the state and nation so you’ve got so many diverse backgrounds, you’ve got people who are coming from areas that maybe aren’t as diverse as other areas and so it could be a different cultural experience altogether when you move to a big city like Dallas.

Dr. Holyfield: Well, we have one of the most diverse student populations of any dental school and I dare say that at one time we had the most diverse population and that’s thanks to programs like our pipeline program that helps to prepare underrepresented minority students for dental education. That diversity is good because we learn from each other. We help each other understand our differences and our preferences and it makes it more palatable and it helps to strengthen us in terms of being able to look at our biases and our perceptions and work through anything that’s negative so that we can build stronger clinicians. It’s a good thing that we’re as diverse as we are.

Lindsey H.: Yeah. Totally. We talk a lot here at Texas A&M Health about the importance of interdisciplinary education, right? Learning how to work in health care teams. I think this falls in line with that. The more diverse a team is, I think, the better the outcomes are going to be, the better the care is going to be and the better the scientific perspectives will be. I mean, bringing different cultures together to look at a common problem with different perspectives I think is really valuable.

Dr. Holyfield: I agree. Dee, go ahead.

Dee Dee G.: I also think that helps with patients as well because you get a lot of people who like to have a doctor at least see a doctor that looks like them and gives that perception of, “They understand my problem,” not necessarily, “If I go to someone else, you understand my culture so you can understand some of the barriers or issues that may come up when dealing with health care issues.”

Dr. Holyfield: Dee, that statement about wanting to find a health care provider who looks like me, is so profound and that is the main reason we have to teach our students to be culturally sensitive, because it’s unfortunate that the number or the percentage of health care providers who are African American or Hispanic is so low in comparison to their percentages within the population and because people want to go to health care providers who look like them, the fact that there may not be one should not negate the fact that they can get health care by someone who is sensitive to their needs and their preferences.

That’s why health educators need to be sure that we are teaching our students to understand that and to understand different priorities, different preferences, and to be accepting and nonjudgmental when we are treating patients and when we are learning about them and to actually take their cultural preferences into account when we are making recommendations and treatment plans because you can plan all you want for them. If it’s not within their scope of preferences then they may or may not accept and comply with that treatment. You have to negotiate the treatment based on what they are willing to undertake or allow to be done.

Lindsey H.: What can patients do to locate a culturally competent or a culturally sensitive provider? I know that can be really hard to find if you’re just searching the web. What are some things that patients can do?

Dr. Holyfield: Other than knowing of a provider’s background in terms of ethnicity, the best way for a patient to learn about a provider who is going to be culturally sensitive is through word of mouth. It’s usually going to be someone who has gone to an office and has found that that dentist is compassionate, caring, and culturally sensitive. That patient is going to leave there and go tell a friend or family member and so that’s going to just trickle on down through the community. That’s the only way. I don’t think anybody advertises … Somebody may advertise that they’re bilingual or that they speak a certain language but nobody is going to advertise that they take care of all patients based on preferences. At least, I’ve never seen that. It’s really word of mouth.

Dee Dee G.: What can a patient do or what can we do when we’re going to a doctor to advocate for ourselves? I mean, it’s a lot different … Like the example I gave with my sister, I mean, the good thing is that my mom was there and so she could advocate for her when she has an issue. If you’re alone and you may be on medication and not really quite … In your right mind, to some degree, but not exactly because you’re on medication, you’re not really able to advocate for yourself so they’re not really going to listen to you. What can someone do to help advocate for themselves?

Dr. Holyfield: I would think that the best thing to do is to make sure they have a full understanding before any treatment is rendered, if that’s possible. In emergency situations, that may not be possible but to have a conversation so that you and your health care provider get to have an understanding and he or she gets to know you, your preferences and we teach our students to ask if they have any cultural preferences or is there any practices that could be a problem with what we’re asking them to do or what we’re asking to do for them. It’s about communication, being able to communicate cross-culturally and make sure that there is a mutual understanding.

The African American race, and I will speak specifically for my family, I recall that there was no one in my family who ever went to the doctor and especially who was hospitalized where they were ever alone. My mom or someone was always going to be there because that was their role to advocate for that family member.

While that’s probably not the practice today, sometimes it may be necessary. As a health care provider myself, when I’m going into an emergency situation I don’t go alone. I’m going to make sure somebody goes with me.

Dee Dee G.: Honestly, I know that’s how a lot of my family members they make sure that there is someone else with them. Like I said, my mom she was there the whole time, stayed in the hospital, made sure that everything was done correctly because I think it’s that fear they’re not going to be taken care of properly without that person there to advocate for them. Makes a huge difference.

Lindsey H.: If minority patients are encountering these biases and they’re experiencing that kind of communication breakdown with their health care provider, do you think that that can contribute to some of the health disparities that we see in minority populations? Do you think that maybe because of these issues they’re not seeking that proactive health care as often as the white majority or the majority in a given population?

Dr. Holyfield: That certainly can be a factor. That lack of trust, if you will, is a factor and because we don’t have practitioners who look like us then a particular race of people will be less likely to go to get the care that they need. Certainly, that can factor into health disparities but that’s just one of the factors.

Dee Dee G.: Especially in the African American community, there’s definitely historical issues that go along with trusting health care professionals from the Tuskegee, those groups, I know gynecology and how the founding of that got started. There’s just a lot of incidents and evidence of why, especially the African American community just does not trust medicine, medical professionals.

Dr. Holyfield: Yeah. That goes back to the fact that we are not necessarily viewed as human. Let’s talk about experimentation that’s sanctioned these days. It’s usually sanctioned to use animals in that experimentation but when you have a group of human beings that you decide are subhuman then it’s okay to experiment on them, it’s okay for them to get diseases or to die when they could very well have been treated and overcome these things because it doesn’t matter. That’s where the problem comes and I dare say that things like the Tuskegee experiment are fading, in terms of knowledge and memory as we grow older and further away from that but there’s still going to be that deep seated lack of trust or skepticism at the very least to make sure.

I went to the emergency room myself and I just wrote my name down, first and last name, Lavern Holyfield, and it was one of the ladies who was registering, the intake coordinator, she asked me to come back to her desk and she said, “You’re a doctor” and I said yeah. She said, “You need to put doctor on there.” That said to me that she knew that differences were going to be made based on who I was, treatment that may not have been rendered.

When she said that to me, it kind of sparked some thoughts and it kind of scared me. I remember saying to the health care provider, everyone that came in, I said, “Listen, don’t worry about the payment. I’ve got two insurances. Just do what you need to do to make me okay” and to this day, they don’t know what caused the issue that I was having but right now I’ve got a team looking at me constantly and they keep up with what’s going on. That’s a good thing but had I just been Joe Blow from the hood, maybe now.

Dee Dee G.: I do find how you said that you had to tell them, also, that you have insurance, you have two insurances, that you were okay, that you can pay for it, which I think is also one of the things that comes up a lot too. It’s like, “You don’t have insurance” but it is interesting. Same with, like I said, my experience is more with my sister’s issue but she did as soon as they found out what she did and where she worked, they totally changed their attitude towards her and it was just the craziest thing I had ever seen. It’s like that’s not how every patient should be dealt with as though they are one of the richest people in the world.

Dr. Holyfield: I say to my students, treat your patients the same, treat them equally and I don’t mean give them the same care because they have different needs but what I’m saying is be as open and honest to them, to each one of them and to make sure that you’re offering them the best care possible regardless of who they are, where they come from, or what they have.

Lindsey H.: Yeah. I said this in the last episode, I’ll say it again. I mean, if you’re not in the health profession to provide compassionate care to patients and to value human life, I just feel like maybe you’re not in the right business. You know what I mean? Don’t do it for the money. Do it for the humanity of it, right?

Dr. Holyfield: I agree. It’s more important that we are there to render the care that a patient needs than it is to get rich. Nobody goes into dental school to be poor for the rest of their lives. They want to have a profession that’s going to sustain them and that’s with any health care profession.

That shouldn’t be the primary thought when you’re taking care of a patient. “How much can I get if I do this versus that?” Or, “I’m not going to do this because they probably can’t afford it.” You need to be compassionate and concerned enough to want to render the best care possible for a patient. If you see that a patient may not be able to afford it or it’s out of your scope then make sure that they get to the right place. There are clinics across this country that take care of patients who have low incomes. If, for some reason, you just can’t do it, don’t just dismiss them, don’t just disregard what it is that they need. At least, have a decent referral system to help them get to where they need to go.

Lindsey H.: What can white allies do in the fight against health disparities in America?

Dr. Holyfield: That depends on what their role is. If they’re health care providers then they need to make sure that they have examined themselves, that they understand their biases, implicit and otherwise, and that when they are treating someone who is different from them, they bring those biases to the front of their minds so that they can manage them as opposed to allowing those biases to dictate how they proceed.

If it’s the insurance companies, make insurance available to all people. If it’s politicians, make rules that are going to make it wrong and against the law to withhold treatment from people because of who they are, what they look like, or what they have. It takes a whole group.

I dare say that African Americans, in particular, have been struggling a long time and we’ve cried out against these struggles. Sometimes it’s been controlled, sometimes others have gone a little beyond what we want to see. African Americans alone, Hispanics and African Americans together, are not going to be able to make the differences that need to be made without the help of our white counterparts.

We need the help of everyone who cares enough to make sure that everyone is getting treated fairly to speak up, speak out, and do everything within their power to help change the situation.

Lindsey H.: I think that starts with just awareness. I think it’s easy for people to ignore it or to be in denial or just to be naïve to it. It doesn’t happen to me so how can it be impacting other people, right? I think it’s important for people to educate themselves, read the articles, listen to the podcasts, watch the documentaries. I mean, listen to our Black brothers and sisters who are saying that this is an issue, because it is an issue.

Dr. Holyfield: You know, I try to find a silver lining in things and that is a silver lining in COVID-19 because even though African Americans and other minorities knew that we suffer disproportionately, there were our white brothers and sisters who may have heard it but it just didn’t register until we find out that 60 percent of the people who are dying are of color.

It’s not that we have been crying wolf. There really is a problem. If COVID-19 has done nothing else, it’s made more people aware of our plight. I’m grateful that it’s made more people or has given more people an incentive, a motive to get up and to help champion our cause. Again, COVID-19 is not the best thing that could have happened to any of us but there is that silver lining.

Dee Dee G.: As you said, there’s a silver lining. As you’ve been teaching the new generation of medical professionals, do you see it changing? Do you see that the skies are starting to open up and that we won’t have this problem in the near future anymore?

Dr. Holyfield: I wish I could say, yes, I see that, but in all honesty, I really can’t see it because I’m not out in the communities looking at what our students that have finished are doing. I just have to have faith that they’re taking what we’re doing to heart.

I do know that one of the questions we ask them as they are preparing to graduate is if they will be treating patients who are different from them and the majority of them, 90+ percent of them say yes. Based on that, I think there is going to be a difference. I think there already is one and that it’s to improve but I have no data to support that.

Lindsey H.: If we’ve got current practicing health care professionals listening to this, what is an exercise that they can do to identify some of those implicit biases or steps that they can take to improve their treatment and care of patients who are different from them?

Dr. Holyfield: I guess one thing would be to look at someone from a different group and think about everything you’ve heard about that group and see what it is that that one individual, how that one individual does not conform with what you really think that group does. I mentioned the term individuation earlier. When you start individuating, you’re looking at a person for who they are, not for who they belong to, what group they belong to but what that person is all about. When you start looking at individuals as opposed to looking at groups based on those stereotypes and generalities that you grew up with, and a lot of these things we brought from childhood on, then you have a better chance of learning to think about each patient as an individual instead of a patient who belongs to a group.

Dee Dee G.: I know one of the issues that always comes up also is access to care and so especially within majority minority neighborhoods there’s an access to care issue. Do you think that also contributes a lot to the issues? I know a lot of those neighborhoods don’t have mass transportation in their area so they can get to where they need to go, I mean, there’s also food deserts and things like that, which all contribute to health issues but a lot of it also is those issues are really concentrated in minority areas. I don’t know what can be done for that. I see some groups come in and try to help that out but a lot of that, that’s a greater problem within cities and states.

Dr. Holyfield: You’re correct. Access is a problem. To health care and nutritious food. It is a socioeconomic problem as well. What happens is when an individual finishes their training as a health care professional, they are more likely to setup shop, open an office in an area that’s more affluent and so that just exacerbates the issue.

Transportation is a problem. If you’re not feeling well, you don’t want to stand on the bus line or sit down and wait for a bus. You probably can’t afford the cost of a taxi to get from where you are to where help is. Now we have ride shares that still may be outside of what an individual can afford.

Yes. This all contributes. Access to care is a major contributing factor to health disparities. Dee, even if somebody had access and we ruled out that as a problem, we made access … Everybody was able to access the care they needed, health disparities still persist among minority populations. It is a racial and discriminatory issue that has to be changed.

Lindsey H.: Yeah. We talked earlier about the mistrust that, especially, the Black community and minority communities have in the health professions and currently there are a lot of companies and organizations who are running clinical trials for a COVID-19 vaccine, that’s one of the main initiatives across the globe right now is getting a COVID-19 vaccine to market. You know, you see headlines, at least I see headlines almost daily that they’re struggling to get representation in those clinical trials from the minority communities.

Is there something that we can do to improve that? I know we talked about all of the things that have led to this. There’s that historical mistrust. I imagine it’s going to take a long time to get to where we need to be where everybody is equally represented and that everybody is getting the compassionate and quality care that they deserve but is there anything that you think we can do to improve the participation of minorities in these clinical trials.

Dr. Holyfield: I can think of nothing that can be done immediately. Even having town hall meetings where health professionals come and talk to minority groups, that historical distrust is a factor. I don’t see that anything is going to happen to change that any time soon.

Dee Dee G.: I’ve seen, obviously, we have some trials going on ourself and I think that’s an FDA requirement is that they have a certain percentage of minorities when they do these trials as well. Yeah. That’s a struggle because then it goes back into, which you keep hearing, if there is a vaccine that comes out with COVID do you trust it and will you take it? That’s going around as well, which I think is going across the board but I know specifically within minority groups they’re like, “I’m not going to be the guinea pig for you today.” Is there a way to get past that? Like you said, I think it’s just going to take some time.

Dr. Holyfield: Yes. I agree. It’s just time I think.

Dee Dee G.: I think also as we get more minorities within research, jobs, as the different health professions because the health profession does not always just mean the doctor, lawyer. You have researchers that are also there in the … They’re just in the back end side of it. I think if we get more representation within those communities, you may have more of a trust situation where they may go ahead and sign up for the trial.

Dr. Holyfield: I wish I had the answers but I don’t because erasing years of concern, of mistreatment, experimentation and just a lack of recognition as an equal being, it’s going to take a while. That’s a lot to erase over a long period of time. I hope that I get to see it in my lifetime but I can imagine it’s not going to be overnight but hopefully it will happen someday.

Lindsey H.: Thank you so much for this conversation. It’s such an important discussion to have and we’re going to continue this conversation for years to come as long as it takes. I know we’re doing as much as we can at academic and research level to try and address these issues and anybody out in the communities who are listening in on this, Dr. Holyfield outlines some things that you can do to advocate and really get out there and make a difference so thank you very much.

Dr. Holyfield: You’re welcome. Thanks for having me.

Tim Schnettler: Thank you for joining us on Texas A&M Health Talk, a production of the Texas A&M University Health Science Center. Visit us on the web at vitalrecord.tamhsc.edu where you’ll find answers to all of your health questions. Until next time, stay healthy.