Racism: A Public Health Crisis Webinar

A candid look at the inequities in health care delivery systems

“I think that everything that we have talked about today is polarized when you're talking about the African American male. In every system across the US, they are targeted and a lot of times, especially in nursing, they have a hard time coping and deal with more microaggressions than even African American women.”  

Samantha Gambles Farr is an adjunct clinical professor at USD SON, president of the San Diego Black Nurses Association, and a board-certified nurse practitioner who has worked in health care for more than 20 years.  The quote above is part of an answer to a question posed by a USD SON alumnus during the first in a series of webinars on Racism: A Public Health Crisis.

The discussion was an hour-long, candid look at the inequities in health care delivery systems between Black patients and their White counterparts.

“We want nurses to look like the American public,” Dean Jane M. Georges said. “Nevertheless, the number of people of color who are actually working as professional nurses is actually quite small.”

The intent of the webinar was to begin the discussion with our students, our alumni, and our community. Dean Georges moderated the discussion. Professor Gambles Farr was joined on the panel by Trista R. Campbell, PhD, RN, CPHQ, a 2017 USD SON PhD graduate; and Kiiyonna L. Jones, PhD, RN, a 2019 USD SON PhD graduate.

Below are some answers to questions posed to the panelists by Dean Georges.  Below those questions are answers, mostly from Dr. Trista Campbell, to questions posed in advance of the webinar by our attendees.

If you would like to view the webinar, please click here.

Q: Jane Georges - Let's talk about evidence of health disparities across populations in the United States.  Are there differences in the outcomes, for example, between white Americans and their black counterparts? And do we have the documentation?

 A: Kiiyonna Jones - I've actually had had conversations with people regarding the same topic. And it made me kind of dig deep, as far as what's out there in the literature and what is it safe. And I found it interesting that in 2003 the Institute of Medicine released a report about unequal treatment confronting racial and ethnic disparities in health care on a system level. Practically every system that we have in the United States has shown that it has been connected to racism. Some of those examples are mortgage lending access to housing, employment, criminal justice, all of those systems have had racial disparities that have been clearly documented. In 2008, the World Health Organization report on health equity led to our US Department of Health and Human Services creating the social determinants of health framework. In addition to that, if you come from a background, for example as me, where it's more humble. I'm from south LA; I’ve experienced it firsthand. So I feel like a lot of times we want to ask for the facts and even when we’re provided them, they're still not received. The problem is you have to be in a position where you ready to receive what you're asking for. And then you have to be prepared for what you're going to do about it. And I think that's the most challenging time for a lot of people; what do we do now, if we accept it if we admit it, then what's next.  

Q: Jane Georges - In what ways does racism affect health care delivery in the US?

A: Kiiyonna Jones - I can speak from working at two hospitals in Los Angeles that are essentially polar opposites; one being in an urban minority community considered a safety net hospital and the other being in a more affluent area with celebrity patients. I'm just going to give one example that really stuck out to me and that is the way in which we label our patients. In the small community safety net hospital, oftentimes when our patients are in pain, even if it was post-surgical pain, they were often labeled “seekers.”

 In nursing school, we're taught that pain is what the patient says it is. It's very subjective. And although we try to quantify it, it is what the patient says it is. However, in the other hospital, the more affluent hospital, patients were often labeled as having a high tolerance. A lot of excuses were made for the amount of pain medication that would be administered, but the derogatory term of “seeking” was rarely ever used. And so because of these labels, the management of pain was not as good in the more urban south LA hospital than it was in the more affluent hospital.

 (NOTE – a “seeker” is a derogatory term used to label patients believed to be seeking drugs due to an addiction.)

 A: Trista Campbell – I would like to tag on to that. We're talking about a population that for decades and decades suffered suppression, depression, and racism. How did these people get that way? If they are drug-seeking, they’re trying to self-treat and to deal and cope with day to day situations, to get up and go to work and face racism, day in and day out with a smile, and with gratitude. And I just think that these are conversations we have to have. It’s a very complex problem and it's not going to be resolved overnight. It took hundreds of years to get here. 

 Q: What are the panel of females’ thoughts on the disparity and racial gender racism experienced by black males who are RNs struggling in a female arena. I can relate to the struggle.

A: Samantha Gambles-Farr - I think that everything that we have talked about today is polarized when you're talking about the African American male. In every system across the US, they are targeted and a lot of times, especially in nursing, they have a hard time coping and deal with more microaggressions than even African American women. This goes back to implicit bias a lot. And this goes back to having prejudice thoughts. We know that this conversation is a conversation that African Americans have been having forever.  And this conversation has not changed for us. So this task and changing things how as it relates to African American men and African American women having access to education and how they're affected really has to go back to people who don't look like us. These are the people who really have to deal with their social prejudices because we all have them. But that's not just dealing with White or Caucasian people, that's dealing with other people of color as well. We know that African Americans across the continuum in every race is thought less of.  The color of your skin makes you less than and being a black male definitely makes you less than, and that's how the whole movement actually started with the murder of George Floyd because this has nothing to do with evidence-base. It has to do with humanity. It has to do with someone crying for their mother as they lay on the ground. And so understanding that this has to do with not just someone we see is our patient, but these are people sons and daughters that are striving to do better for themselves. And we have to deal with that on a human level because that's what nursing is; we take care of people. We are human. At the end of the day, we need to treat people as we treat our families, and as we treat each other.

A: Trista Campbell - I was the first Black female RN hired into the SICU where I was employed. I was always being set up for failure by given the worst patient assignments, especially when I had to float to other ICUs or worked registry. Staff members would not readily cover my patients for lunch and/or breaks. Many times I would go the entire shift without eating, for fear my patients would be neglected. There were a lot of false assumptions regarding my competencies; I was always having to prove myself.

Q: Do you think that it is helpful to consider race as a continuum as well as a category so that we can expand our thinking to not only include color but also culture yet still acknowledge color?   

A: Yes. However, the priority would be to determine a shared understanding, the original purpose, the dynamics that drive the current environment, along with determining an agreed-upon definition of racism. The hues of your skin tone play a big role in the severity of racism on individuals. Remember that racism has been a part of the United States since its inception along with slavery.

Q: What can I do to get involved in a volunteer capacity?

A: Begin by participating in group discussions and/or activities related to social injustice.

 Q: How can we be culturally sensitive when addressing racial health disparities, as they relate to stroke, high blood pressure, cancer, OB postpartum complications, PTSD, alcoholism, substance abuse, and homelessness?

A: Our health care workforce comprises a compendium of professions founded on the principles of scientific inquiry and evidence. Despite the science of what race is and is not, the American health care system has a history of navigating within a structure of differential treatment predicated on the social construct of race. This is a history that began with the legalized system of human possession called slavery. White physicians exploited skin color as a medical indicator to expand plantation workforce efficiency, defend colonial and civic interests, and exert greater control over slave laborers.

We need to approach it from the cause and effect process to get to the root of the problem and to be able to decrease these bad outcomes. Mental health is subpar for this country and more so for these populations. No one wants to talk about the elephant in the room; the lack of resources, trust, and access to behavioral health resources. The pipeline to prison processes needs to be addressed and eliminated. Most of this work needs to start on the federal and local political levels in making quality health care accessible to all. We need to create community resources to educate the people about racial health disparities. We need to build trust within the people in these communities, so they will freely engage in accessing health care and participate in research studies.

Q: How can more people of color be recruited into the health care professions?

A: Unfortunately, this will have to be valued and initiated at the health care organizational level. Many employers expand on the word “Minority;” The smaller part of a group, a group within a country or state that differs in race, religion, or national origin from the dominant group. According to EEOC guidelines, “minority” is used to mean four particular groups who share a race, color, or national origin. As you may know, there is a financial benefit in recruiting health care minorities from outside the country, even though these actions don’t help with the deficit of aligning staff to match the patient population, according to The Joint Commission. Organizations need to increase compliance with aligning staff to the same ratio as the patient populations being treated.

Q: I am raising my two children as individuals who will respect all beliefs, all sexual orientations, all skin colors, all socioeconomic statuses, and all body shapes, "to love their neighbor as they love themselves." Besides voting at the local, state, and federal level, what else can I do to contribute to the cause of minimizing, or even eliminating, racism?

A: Respecting all the mentioned beliefs issues above is not enough; we need to better understand the etiology as to how we got here. Begin to ask ourselves the question of “why”? None of us has all the answers.  We need to develop policies, systems, and programs to address the growing disparity. We have come a long way. However, I think we still have a very long way to go to resolve this disproportionately large burden of morbidity, premature, mortality, and disability in Blacks. We have come a long way through the eras of reconstruction and civil rights, state and federal legislation such as the Jim Crow Laws and the Hill-Burton Act of 1946. These were lynchpins for discriminatory practices relative to equitable health care.

Q: How can we improve the education we provide to our students?  We cover implicit bias and social determinants of health but that seems inadequate.

A: I like to use the analogy of a car. It can be a beautiful specimen; however, the engine can’t turn over and move the car unless a few things are working properly (i.e.: gas, coolant, tires, oil, etc.). If these things don’t work, you will have to push the car and it will only move if you use a lot of manpower to push it. So, we must teach our students to assess for all of these essential items to assure the car can run on its own for some time. If not, it’s going to unexpectantly stop!

Q: How can nursing faculty better prepare nursing students to address racial inequality within the health care system?

A: Change the curriculum to include a scientific methodology to assess for engagement readiness, along with including a community assessment when creating the plan of care for the patient. People who are clinically depressed or suppressed can’t readily engage self-care.

Q: How can racial bias be addressed/corrected among providers in a non-punitive/punishable way to people who may not know they are being racist?

A: When I was employed at a large health care system in southern CA, all new hires were required to go through a two-day orientation called “It’s All About Caring” and it was mandatory to attend an all-day course on how to have “Crucial Conversations” and “Conflict Resolutions”. This training provided staff the tools to not be intimidated by strong personalities. Also, now the accrediting agency of The Joint Commission has now added standards addressing civility in the workplace (see links below).

Quick Safety 24: Bullying has no place in health care

You can also download the PDF

Q: What is being done to encourage Black people to choose the nursing profession?

A: High School open houses, more recruitment, and involvement in the National Black Nurses Association.

Q: Seeing statistics show so many black women are dying giving birth what do you believe can be done to close that gap within the healthcare systems?

A: Addressed in shrinking the disparity gap.

Q: How can more people of color be recruited into the health care professions?

A: Improve patient experiences of the Black population in the healthcare setting to make it more desirable and enticing to people of color.

Q: With regard to color, blind spots, and some for and against black lives matter, looking to replace BLM with all lives matter- what’s the best way to advocate against racism and still stand for all people are created equal. I believe that Black lives do matter and I believe that all lives matter too but saying black lives matter, in my mind, takes nothing away from anyone else. I’m not sure why some people can’t say black lives matter, too! I’m looking for my own blind spots and trying to be more self-aware. How do you speak to these kinds of statements? What do you think helps fight racism best?

A: I think stating All Lives Matter is a copout, that is assuming that we are already all on an equal plane and it takes the focus off the growing problem.

Q: How can I make a difference?

A: Start by developing comfort in having uncomfortable conversations and make a commitment to get involved in an area you already have a voice.

Q: Are there discussions related to local university led residential and community-based health clinics staffed by physicians, nurses, and APRNs serving vulnerable populations where student physicians and student nurses (undergraduate and graduate nurses), and allied health students complete clinical practice hours to acquire the knowledge and skills to recognize and help prevent health disparities?

A: Others to answer, they are more appropriate to speak to this issue. Begin addressing the problem of APNs not being able to function independently in California.

Q: The civil rights movement of the 1950s and 1960s, and the sacrifices made by those who were a part of it, were effective at improving (maybe not as much as we would have liked) racial inequalities. Are the current protests and movements throughout the country being as effective as the civil rights movement, or are we due for another movement of that magnitude to create the change we desire?

A: I think the current movements are more powerful than the 1950s and 1960s due to the fact there are more people involved (there is power in numbers). There are more available funds to support the cause (i.e.: NBA, NFL players, etc.), many large corporations are supporting the cause and social media helps spread the news to engage the masses.

Q: Do you have suggestions for resources for images to use in teaching? We have many available images to assist in where we need to begin to address the problem.

A: My hometown of Clairton, PA is known as a food desert and a third-class city. Based on the scientific evidence that we are what we eat, this will have to be addressed to improve the quality of health of the Black people.

Q: How do we bridge the gap in race-specific evidenced-based care when the majority of knowledge at this time is Caucasian male/female based? i.e. heart attack, childbirth, etc.

A: Increase collaboration in research, for example, MD/RN research, professional organizations, and work with licensing, accrediting and regulatory organizations in establishing and improving the collection of data to be all-inclusive in developing standards of practices.

Q: What can Schools of Nursing like USD do to help inspire more Black people to join the nursing profession?

A: We need to think of the entry point and throughput. As a university, USD can develop a CNA program and partner with a local high school with a predominantly Black student population. When I was on the State Board of Nursing in AZ, we made it a mandatory requirement for entry into a Nursing program. This helped weed out those who enter the profession for the money and not for the passion. This created opportunities for students to have career development with the same employer, and it also creates a means of income with flexible work hours for those who need to provide for themselves along the way. I’m the product of a program called SIN, Success in Nursing, this was back in the 1970s at Phoenix Community College. It was not just for Blacks, we had Native American, and Hispanic students as well. The program had smaller groups for the math and science classes for the first three semesters and we were merged with the larger group at the last semester of the ADN program. 

Q: What should I be doing today that I might not be doing to help stand against racism?

A: If you see something, say something. Be able to start or hold healthy dialogue so we can gain a better understanding of the ongoing racism. If you’re not a part of the solution, you are part of the problem.

Q: What are the lessons learned from the military with health disparities related to traumatic events, both before and after military service?

A: The lack of mental preparation prior to after being deported or sent to battle. The delayed access to care, the lack of respect of those who have served our country.

Q: How can we address the lack of racial difference in case presentations of common medical concerns?

A: This can be addressed by changing the construct of the assessment findings. Many times we see or hear the statement, “This is a 44-year-old pleasant AA female, etc.” Under that pleasant persona, there may be a very depressed woman. We have been taught to be respectful, kind, and smile, this is to give hope of being treated fairly. We need to be more thorough and/or scientific in the assessment of the mental health of individuals. We need to care for the whole person. An individual dealing with any type of behavioral health issue will not be able to care for their physical illnesses if we don’t assess and treat mental health simultaneously.

Q: At what age/grade is it best to start nurturing young Black people to follow the path toward the nursing profession?

A: I think human caring should be taught at the Pre-K age or when you begin to instill moral values and consciousness into your children. This will identify if the nursing profession is ideal for the child.

Q: When speaking of color, I find it offensive to say I don’t see color; how is the best way to respond to that remark?

A: I think the first thing to do is to ask that person to explain to you further as to what they mean by that statement. I think the individuals who make those statements are saying, the color of someone’s skin is not a deciding factor as to how they interact, think of, or treat someone.

Q: Seeing statistics show so many black women are dying giving birth what do you believe can be done to close that gap within the healthcare systems?

A: Most of this work needs to start on the federal and local political levels in making quality healthcare accessible to all. Create community resources to educate the people about racial health disparities. Build trust within the people in these communities, so they will freely engage in accessing health care and participate in research studies.