Racism in Healthcare: A Black Physician's Memoir on Systemic Bias

Cultural humility is an ongoing process of self-reflection and learning that recognizes healthcare providers have unconscious biases and power imbalances that affect patient care, whereas cultural competency assumes providers can achieve expertise in understanding diverse cultures; cultural humility acknowledges that we all hold scripts about race and identity that shape our interactions and perpetuate inequities, requiring continuous education and partnership-building with communities rather than assuming we can competently serve all populations.

Cultural humility, first introduced in 1998 by two physicians, is a more desirable goal than cultural competence because it is impossible to master any culture without years of immersion. Cultural humility is a process that fosters openness, self-awareness, egolessness, and self-reflection when interacting with diverse individuals. The resulting outcomes include lifelong learning (necessary because true competence is never achieved), mutual empowerment between providers and patients, and optimal care with respect for patients. Unlike cultural competence which stops at knowing about a culture, cultural humility guides providers toward mutual respect and benefit.

Cultural humility emphasizes being curious about individuals and avoiding assumptions based on stereotypes or group generalizations, whereas cultural competency assumes professionals already know everything about a person's culture and identity; the key difference is that cultural humility involves asking questions to understand each person's unique story, while cultural competency relies on pre-existing knowledge about cultural groups.

Cultural humility is a lifelong process of self-reflection and introspection that goes beyond cultural competency by requiring nurses and educators to recognize their own cultural biases, maintain historical awareness of systemic issues affecting different populations, and commit to continuous learning about the complex and evolving cultural experiences of patients and students, rather than relying solely on static textbook knowledge about cultural practices.

Cultural humility emerged in the late 1990s as an alternative to cultural competency, developed by nurse practitioners Teron and Murray Garcia in the San Francisco Bay Area. While cultural competency focuses on what individuals need to know about others, cultural humility shifts focus to examining one's own position within society and actively prioritizing the perspectives of service recipients. This approach recognizes that no amount of external knowledge or expertise can supersede the authority of lived experience.

An intersectional approach to healthcare recognizes that women face multiple, interconnected forms of oppression based on race, ethnicity, sexuality, class, and gender. Without this approach, barriers cannot be effectively addressed and maternal mortality indicators cannot be reduced. This approach is essential for addressing the specific needs of Black, Indigenous, migrant women, and those in extreme socio-economic vulnerability, with disabilities. The goal is to reduce oppressions and improve quality of life for women in all territories.

Intersectionality in health recognizes that race, sex, sexual orientation, and income status are inequities that add up. Black women are twice as likely to experience maternal mortality than white women, especially when socially and economically vulnerable. The 10 steps for obstetric care include quality consultations, hypertensive syndrome identification, infection screening, and hemorrhagic syndrome recognition. Childcare requires multidisciplinary emergency room support, longitudinal care, and monitoring of growth and development to identify risks early.

The United States has some of the worst infant and maternal mortality rates in the world, despite claims of having the best healthcare. This is due to incredibly unequal access to quality healthcare, where many people cannot access the preventative and prenatal care standard in other developed countries. The US has no federal paid maternity leave. Intersectionality refers to how multiple social identities create interconnected systems of oppression. Black women face compounded discrimination because they are both Black and women, experiencing both racial and gender-based biases in healthcare settings. Even wealthy Black people have worse maternal and infant mortality rates than poor white people.

Maternal health must be understood within the broader context of intersectionality, combining race, gender, and other social identities to understand their combined impacts on health outcomes. Systemic and structural determinants of health include racism, classism, gender oppression, sexism, ableism, and heterosexism. These factors interact and compound each other, creating unique health challenges for women of color. Maternal health cannot be separated from broader social determinants including lack of childcare, education, social infrastructure, and community investments. Black mothers have been more likely to die than White mothers for about a century, as long as data has been collected. Higher rates of maternal mortality among Black women cannot be explained solely by specific medical conditions like eclampsia or postpartum cardiomyopathy. Root causes include increased comorbidities and stress from racism, living in toxic environments, weathering effects of chronic stress, delays in accessing high-quality healthcare, and presenting with more severe symptoms due to these delays. Structural racism creates a hierarchy of human value entrenched in healthcare practices and policies.

Black women in the United States face dramatically higher maternal mortality rates—3-4 times higher than white women, with some areas showing 8-12 times higher rates. This disparity persists despite controlling for income, education, geography, and weight, demonstrating that racism itself functions as a health risk factor. The U.S. has the highest maternal mortality among high-income nations, and unlike other wealthy countries, this rate is increasing. Systemic failures include: healthcare access disparities in urban areas (some DC wards lack labor and delivery services), policy decisions that prioritize other investments over maternal healthcare, and medical practices where Black women's concerns are dismissed. The intersection of racism and gender oppression creates the worst outcomes globally, requiring fundamental policy changes to address these systemic inequities.

Community-Based Participatory Research (CBPR) is a proven method for reducing health disparities through equal partnerships between researchers and communities. Unlike traditional advisory groups, CBPR involves communities in every phase—from planning to implementation to ownership. Effective engagement requires convening advisory groups with lived experience, respected leaders, and hospital staff. Trust-building takes genuine commitment and time—some projects take four years of monthly meetings. The community retains ownership of whatever is created, ensuring sustainability and cultural appropriateness.

Community-Based Participatory Research (CBPR) is a collaborative research methodology that equitably involves community members, families, and researchers in all aspects of the research process, from question generation to dissemination, with the goal of eliminating health disparities and promoting social justice; effective CBPR requires building trust through transparent communication, shared leadership, cultural centeredness, and long-term commitment, while recognizing that research should never harm the communities it studies and that evidence-based interventions must be adapted to fit local cultural contexts.

Community-Based Participatory Research (CBPR) is an approach that incorporates non-academic community members in all stages of research to improve health and promote change. It recognizes the limitations of traditional research methods and values the social and experiential knowledge of community members. True CBPR partnerships share characteristics: building collaborative partnerships with power-sharing processes, recognizing community as a unit of identity, building on community strengths and resources, facilitating co-learning and capacity building, utilizing ecological approaches focusing on social determinants of health, seeking mutual benefit to all partners, disseminating findings to the wider community with all partners involved, and maintaining long-term commitment to sustainability beyond single projects. Benefits include all members feeling comfortable speaking openly, commitment to partnership sustainability, greater potential for research translation into relevant actions, and trust-building between academics and communities. Challenges include limited grant time for relationship-building, sustainability challenges maintaining resources and fairness, and community members having competing priorities requiring flexibility.

This comprehensive section covers two interconnected topics essential for understanding health disparities in marginalized populations. First, it presents detailed health outcome data across four major marginalized youth populations: sexual minority youth face elevated risks across social (discrimination, rejection, bullying), physical (HIV, STDs, unintended pregnancy), and mental health (depression, suicide, eating disorders) domains; rural youth exhibit higher teen birth rates, methamphetamine use, and weapon carrying; African-American youth face the highest homicide and HIV rates with lower life expectancy; Latino youth show the highest teen birth rates and obesity rates; undocumented youth experience compounded discrimination, fear of deportation, and high uninsured rates (69%). Second, it develops the theoretical foundation through the World Health Organization's definition of social determinants as conditions in which people are born, grow, live, work, and age—shaped by distribution of money, power, and resources. The socioecologic framework organizes factors across individual, interpersonal, organizational, community, and policy levels. Allostatic load describes the cumulative burden of barriers across these levels. The section introduces Community-Based Participatory Research (CBPR) as the core methodology for addressing these disparities, emphasizing principles of equitable partnership, cultural humility, and iterative engagement with communities as experts.

Community-Based Participatory Research (CBPR) is a collaborative research approach that establishes structures for participation by communities affected by health issues alongside researchers and practitioners, contrasting with traditional scientific research where experts define research questions and interpret findings. The Greensboro Health Disparities Collaborative demonstrates how CBPR can effectively address health disparities—preventable differences in health burden experienced by socially disadvantaged populations—through sustained partnerships, humility in academic-community collaborations, and action-based research that produces tangible improvements like eliminating racial disparities in cancer treatment completion rates from 79.8% to 88% for Black patients and from 87.3% to 89% for White patients.