Yale physicians confront health care inequities laid bare by pandemic

The COVID-19 pandemic has made existing health inequities more apparent than ever. In Louisiana, for instance, Black people account for nearly 77% of hospitalizations and 70% of deaths while representing just 31% of the state’s health system. And nationwide, the virus is killing Black people at 3.4 times the rate of white people.

This unfolding tragedy is a lens for examining structural racism in health care more broadly, said Max Jordan Nguemeni Tiako, a fourth-year student at Yale School of Medicine who recently co-authored an article on racial health disparities and how U.S. health systems can overcome them.

The article, published in the Journal of Hospital Medicine, was co-authored by Dr. Marcella Nunez-Smith, an associate professor of internal medicine, public health, and management at Yale who will lead a White House task force on health equity, and Dr. Howard Forman, a professor at the School of Public Health, School of Management, and School of Medicine.

“Money buys health, quite literally,” said Tiako.

In the article, Tiako and his co-authors argue that numerous factors led to this point, including unequal health care quality and access, socioeconomic divisions, and riskier work and home situations for Black, Latinx, and Native people.

In terms of access, “Wealthier, private hospitals have better COVID outcomes,” Tiako said. “They have more resources, they are better staffed, and they have more high-end therapies.” 

In New York City, for instance, the public hospitals that serve the city’s low-income residents receive significantly less federal provider relief funding, according to the paper. Health centers on Native American reservations received delayed federal funding. Likewise, since advanced therapies for treating various medical conditions are based on cost rather than illness, the authors note that “only 17.5% of Black patients received additional help [from advanced therapies].” 

These disparities extend to the workplace. Across the country, Black, Indigenous, and Latinx workers are less able to work remotely than white workers and are more likely to have jobs that put them at risk of exposure to the virus, including in the health care sector and public transit. In New York, for example, more than 40% of transit workers are Black (compared with about 24% of the city’s population.)

The staggering disparities, however, can serve as an opportunity to create a more equitable health care system, the authors write. 

In the article, they recommend that health care systems and providers address bias and its effects on patient care, adopt strategies that mitigate structural biases, and address inequities, diversity, and inclusion in the sector’s workforce. 

The authors urge health care systems to collect racial and sociodemographic data and evaluate their processes and outcomes for potential disparities. They also suggest that these systems collaborate with community organizations to ensure that social needs are being met. “This is particularly relevant for COVID-19 survivors who may face long-term chronic physical and mental health issues,” they write.

Workforce equity at hospitals begins with a living wage, Tiako said. “Having more money means you are less stressed, you have better access to medications, and you live in better conditions,” he said. The authors note that hospitals employ the most low-wage health care workers, most of them Black or Hispanic women. Nearly half of these workers earn less than $15 per hour, and a quarter are uninsured or on Medicaid. 

And hospitals must address racism in the workplace, the authors write. Black health care workers experience greater discrimination and barriers to opportunities than their white counterparts, and Black physicians are prone to greater burnout in part due to discrimination, the article notes. It starts with experiencing and witnessing discrimination during medical training. 

To ensure that health care systems provide equal benefits across racial groups means addressing the problem of systemic racism at its roots, Tiako said. “What are medical schools doing to diversify the student body?” he asked. “Where do we look for applicants?”

Medical school curricula need to move beyond implicit bias training, and put greater focus on attracting diverse student populations and creating environments that encourage Black, Latinx, and Native faculty to remain, teach, and serve as mentors, he added. 

“Fostering a culture and structure that champions racial justice and diversifying the health care workforce would synergistically improve non–Black health care workers’ attitudes toward Black people while also improving the working conditions of Black health care workers and the experiences of Black patients,” the authors conclude.