Risha Chakraborty: The Critical Need for Bias Intervention Training for Healthcare Professionals

Anti-racism interventions for healthcare professionals have grown increasingly necessary since the turn of the 21st century. The Civil Rights Act of 1964 spurred concerted efforts among national and state legislation to identify and eliminate racism in healthcare settings, but addressing medical professionals’ implicit biases has remained the responsibility of medical schools and hospitals. Such institutions instruct students and residents with curricula derived from racist roots, causing the majority of healthcare professionals to retain race-based misconceptions of the physiology and psychology of African-Americans today (1, 2, 3). A 2021 systematic review of 37 anti-racism intervention training workshops found that the curriculum disseminating knowledge of racist stereotypes is lacking (1). However, stereotype replacement and counter-stereotypical imaging are two evidence-based strategies that successfully reduced implicit racial prejudice as measured by an implicit association test in college students, accenting the need for a standardized organization of stereotypes contributing to medical professionals’ implicit biases (4). 

The first overarching class of biases pertains to African-Americans’ physiology, whereby they are perceived to experience less pain and illness than white Americans. Until the Human Genome Project in 2003 elucidated that there was greater variability among different ‘races’ than between ‘races’ and proved race to be a skin-deep social construction, Africans and descended people were believed to be genetically distinct from white Americans (5). Together, slavers, slave owners, and scientists such as Thomas Hamilton and the Father of American Gynecology J. Marion Sims manufactured the perception of African-Americans being less likely to feel pain to justify physical abuse across space (6). Slave owners used physical torture and mutilation to keep slaves in control, doctors used slave women as test subjects to develop gynecological procedures, and army surgeons underprescribed pain medication toAfrican-American Civil War soldiers (5, 8, 9). Today, African-Americans are less likely to receive pain medication in the emergency room (6), in the clinic (10), and post-surgery, and are more likely to undergo painful procedures such as amputations compared to white patients (11). Renowned doctors such as the Father of American Psychiatry Dr. Benjamin Rush institutionalized the perception that African-descended peoples were immune to diseases such as yellow fever and tuberculosis (13, 14, 15). Today, African-American people are less likely to receive critical treatments for respiratory illnesses such as COVID-1916, strokes and long-term diseases such as organ failure, when they present the same symptoms as white patients (11, 17). 

The second overarching class of biases pertains to African-Americans’ physiology, whereby theyare perceived as less able to control their impulses and thus more likely to engage in risky behavior. Such perceptions underlie negative outcomes across diverse healthcare settings including sexual health, psychiatric health, and addiction. This impression of the African and African-descended person’s psyche originated with the institution of slavery in the United States and served as the justification for the subjugation of entire societies. British and American slave-ship captains attributed West African peoples’ violence against each other and their captors to a fundamental lack of self-control (7). White Americans perpetuated the impression of African-Americans lacking control over their own behavior through the antebellum and Civil War period. Antebellum doctors created novel ‘mental illnesses’ including “Drapetomania”, a ‘disease’ that ‘caused’ slaves to try to escape their plantations, and “Dysaesthesia Aethiopia”, a slave-specific term for clinical depression (18). The creation of specific mental illnesses nucleated the trend of misdiagnosis for the exact same presentations between African-Americans and white Americans by assuming ‘clinical’ behaviors were based on innate race-based characteristics, such as belligerence and laziness (13). 

The end of slavery at the end of the Civil War removed the economic scaffolding that protected African-Americans from white Americans, as white Americans feared African-Americans having the ability to establish their own livelihoods. White writers at the time wrote about African-Americans reverting to criminal savagery in their freedom, and many were mentally or criminally institutionalized in response (19). Anti-black propaganda at the beginning of the 20th century impressed the stereotype of the “black brute” - African-American men who raped white women - which rationalized white Americans ransacking African-American neighborhoods, capturing African-American men, and lynching them (18). Newsletters and scientific journals also cultivated the “Jezebel stereotype” - the feral African-American woman (20). White men raped African-American women without repercussion, perpetuating the Jezebel stereotype. 

In addition to hypersexuality, white Americans began associating African-Americans with poverty, violence, and beginning in the 20th century, substance abuse, correlated with the development of the African-American neighborhood. Through the Reconstruction Era, the majority of African-Americans were forced to continue to work in plantations as sharecroppers and domestic homemakers, necessitating African-American pockets of space to develop adjacent to white plantation neighborhoods (21). After the Compromise of 1877 ushered in the Jim Crow Era, southern urban centers such as New Orleans and Montgomery were legally segregated and African-Americans were forced to access the facilities, schools, and institutions only in their particular neighborhoods (22). Federal, state, and local funding was funneled into white neighborhoods at the expense of African-American neighborhoods, furthering dilapidation.

When World War I began, able-bodied white men who used to work in factories in urban centers in the North and West were enlisted, enabling African-American southerners to relocate and fill these industrial jobs (24). Millions of African-Americans faced similar injustices in Northern and Western cities. White Americans in metropolitan centers such as New York, Chicago, Detroit, Oakland, and San Francisco, previously accustomed to a small smattering of the African-American families across the city, created residential boundaries that penned migrants into black-only districts through redlining policies (24). Unemployment rates increased, the population was violently controlled by state and local policing, and urban violence escalated (18). 

The perception of African-Americans as hypersexual and violent individuals aggregated in inner city ghettos coalesced during the confluence of the AIDS and crack cocaine epidemic in the 1980s. The first cases of HIV were identified among men who have sex with men (MSM) in New York in 1981, converging with the early acknowledgement of African-American MSM (25). Newspapers and doctors regarded them as having condomless sex that put their female partners at risk for HIV, reinforcing HIV as an ‘African-American disease’ (25). Assortative mixing - the tendency for individuals to have sex with others within the same racial group- made HIV disproportionately prevalent within African American communities (26). 

In 1984, as crack cocaine became popularized as a drug-of-choice in American cities due its low cost-per-dose and convenience of consumption, populations of crack cocaine users and AIDS patients intersected, propelling the bias that crack cocaine users lived primarily in African-American metropolitan communities infected with HIV(27). Disparities in HIV infection did not result from differences in rates of high-risk sexual or injection behaviors, but rather higher rates of infection were likely a result of decreased access to needles (26). Needles were accessible only by prescription in cities and African-Americans had decreased access to medical care. Using crack cocaine, African-Americans’ drug-of-choice, entailed harsher consequences compared to using other illegal drugs such as powder cocaine and heroin, so African-Americans reused needles to avoid drawing attention to their substance use (28). Nevertheless, associating African-American neighborhoods with HIV and substance abuse reinforced the perception of African-Americans as lacking control over their addictions and actions. Moreover, as the popularity of crack cocaine was correlated with increased urban crime rates, family structure decay and domestic violence, the media mongered the narrative of the “crack baby mothers” who birthed “crack babies”(27, 29). Because both HIV and cocaine-addiction are diseases that perpetuate from mother to child, African-American babies were considered diseased before they were even born, underpinning the perception that addictive behavior is a fundamental facet of African-Americans’ biology. 

Turning the Implicit Explicit: 

Over African-American history, the perception of African-Americans being more likely to engage in risky behaviors have caused them to be labeled as violent, sexually promiscuous, irrational, and addictive. These labels manifest in detrimental healthcare outcomes today. Fundamentally, such biases cause medical professionals to focus on African-American patients' behavior over their mood or their medical history, leading to overdiagnosis of African-Americans’ mental illness (30). Belligerence is attributed to conduct disorders instead of lifestyles marked by lower socioeconomic status, leading to the fourfold overprescription of antipsychotic medication to children of color from lower-income households compared to children with private insurance (1). When psychiatrists are presented with the same set of symptoms from African-Americans and white Americans, African Americans are mis- and over diagnosed with psychosis, while affective disorders go undiagnosed, resulting in African-Americans being more likely to commit suicide than their white counterparts (31, 32). 

Healthcare providers prescribe HIV pre-exposure prophylaxis (PrEP) based on patient risk compensation; if they believe patients are more likely to engage in risky behavior, they are less likely to prescribe PrEP (25). Since medical professionals view African-Americans as sexually promiscuous, they are less likely to offer African-American patients STI prevention than white patients, even though African-American patients would likely benefit more from HIV prevention because of the prevalence of HIV in the African-American community. Medical professionals today perpetuate this stereotype of sexual promiscuity by automatically presuming that African American adolescents are sexually active (33). 

Healthcare providers are also less likely to treat African-American patients with crucial surgeries and inpatient interventions including transplants, mastectomies, reconstruction surgeries, and coronary bypass operations because physicians unconsciously believe patients lack the control to adhere to post-surgery regimens (34). Thus, not only do healthcare providers ignore the traditional treatment plans for time-sensitive and lethal disease including heart blockage and cancer because of the physiological bias, but the psychological bias compounds such mistreatment. 

Finally, African-Americans are less likely to be successfully treated for addiction when diagnosed with a substance use disorder than white Americans, both because they are significantly less likely to receive a prescription for addiction-tempering medications such as buprenorphine and because they are asked to leave treatment prior to their program’s completion when they are admitted to rehabilitation centers (35, 36). Underlying both these trends is the belief that African-Americans are more likely to abuse drugs (37). Since the underlying bias is that the addictive personality is ingrained in the fundamental racial characteristics of African-Americans, treatments are perceived as futile and accordingly, addiction shifts from a medical problem to a carceral problem. Instead of treatment, African-Americans continue to be arrested for drug possession and use despite uniform rates of substance use among racial populations. 

Therefore, the physiological and psychological biases of medical professionals outlined in this novel paradigm manifest in compounding ways, culminating in negative healthcare outcomes for African-Americans in the modern day and necessitating anti-racism bias intervention training. While the stereotypes comprising the physiological bias have begun to be addressed, the psychological biases are often overlooked in stereotype replacement and counter-stereotypical imaging implicit training interventions. Nevertheless, both categories have pervasive implications in African-Americans diagnoses and treatments across the medical fields. Medical schools and hospitals must develop interventions that integrate both biases with the hope that medical professionals will one day treat African-American patients independent of physiological and psychological preconceptions.

Risha Chakraborty is a Junior at Yale University in Saybrook College

References: 

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