February 12, 2024

On Wednesday, February 8, the Urban Health Collaborative had the pleasure of hosting Dr. Brian D. Smedley, a national thought leader in the field of health equity who is currently an Equity Scholar and Senior Fellow the Urban Institute. The title of his talk was “How Can We Accelerate Progress toward Healthcare Equity?” and to illustrate the current pace of progress, Dr. Smedley referenced a 2003 report by the Institute of Medicine: Unequal Treatment, Confronting Racial and Ethnic Disparities in Health Care. Dr. Smedley was an editor of this report, which documented the effects of bias and structural racism on patient care. Although the findings were no surprise to the public health community, It was the first time that many in the American public were confronted with these disparities and their causes. Twenty years later, Dr. Smedley explained, very little has changed.

According to the 2021 National Healthcare Disparities and Quality Report, people of color continue to experience significantly worse care relative to the white population, and very few health disparities have narrowed. Patients of color are less likely to receive preventive or specialty care. When they do receive care, they are more likely to wait longer for treatment that is often inadequate. Plus, Dr. Smedley noted, our current healthcare inequities are driven by many of the same factors cited in the 20-year-old Unequal Care report, from individual provider biases to larger structural factors that unequally distribute health care resources and offer lower reimbursement rates for lower-tier health insurance plans.

These inequities result in worse outcomes in a range of conditions, as documented by Dr. Uche Blackstock’s essay comparing her experiences working at two New York City hospitals, one private, one public, that offered a very different quality of care. Dr. Smedley urged us to read Dr. Blackstock’s essay not only for its stark descriptions of “hospital segregation,” but of the bigotry that she experienced as a Black, female doctor. People of color experience multiple structural barriers that decrease their odds of becoming health care professionals. This lack of representation is yet another driver of health inequities, particularly among Black patients. On the other hand, Dr. Smedley noted, Black patient outcomes significantly improve when they are treated by Black physicians. For example, Black infant mortality, which occurs at three times the rate of white infant mortality, is halved when these babies are delivered by Black providers.

So how can we make progress toward healthcare equity in America? There are no simple remedies, Dr. Smedley says. Racism has many forms, and these forms often work together. For example, structural racism often limits people of color to lower-tier health plans and lower-quality health care institutions. These institutions often limit the time that providers can spend with patients, as well as the resources available to treat them. In the absence of time and resources, providers are more likely to act from personal biases and racial stereotypes, resulting in poorer quality of care for patients.

Dr. Smedley and colleagues discuss these challenges in their recent book, Unequal Health: Anti-Black Racism and the Threat to America's Health, which analyzes the effect of individual and systemic racial bias on health disparities and proposes approaches to bring us closer to achieving structural, institutional, clinical, and educational equity. “We are in a period that offers both progress and peril,” Dr. Smedley said, citing the wealth of information on racial health inequities and their causes, and the political pushback against any policies that could not only alleviate these disparities, but benefit everyone's health. He ended with a quote by Dr. Mary Basset that sums up the urgency of the moment: "Understand that anti-racism is not a witch hunt, but a collective healing, without which our nation will remain painfully and inequitably divided, corroding opportunity, spirits, and bodies alike."

Watch the full talk: