IHI Open School Short

Video Transcript: Does Racism Play a Role in Health Inequities?: A Conversation Between Donald Berwick, MD, and David R. Williams, PhD, MPH

Donald Berwick, MD, Senior Fellow and President Emeritus of IHI
David R. Williams, PhD, MPH, Professor of Public Health, Harvard T.H. Chan School of Public Health

BERWICK: Is this racism? Is this racism in society and in health care?

WILLIAMS: Racism is a significant contributor, I think, to it, in multiple ways. Some ways in which the racism is obvious to individuals, and many ways in which racism is not obvious to individuals. So let me give a couple of examples.

Back in 2000, I was invited by the Institute of Medicine to serve on a committee that was going to address the question, what happens when blacks and other minorities get into health care contexts in the United States? Does their race or ethnicity make a difference in terms of the medical care they receive? The report by the IOM released in 2003 was called Unequal Treatment. And what it documented that was across virtually every class of medical procedure, from the most simple to the most complex, minorities receive poorer quality care and less intensive care. We were not addressing issues of access. The question was, given access to care, is there a difference in the quality of care received?

And we found absolutely there was a striking difference. We do not believe, we did not believe in the Institute of Medicine community, and I do not now believe that American physicians wake up in the morning and say, “How am I going to get my minority patients today?” I truly think that most medical doctors go to work, and other health care providers, and try to do their best for their patients.

If that’s true, then there’s a conundrum here. How is it possible that people with good intentions seeking to do their best can nonetheless, at an aggregate level, create a pattern of care that is so discriminatory? Our answer was implicit bias. It’s also called unconscious or unthinking discrimination. And when the IOM concluded that that was a contributor in 2003, there was a lot of circumstantial evidence. Today, the evidence is even stronger than it was then that implicit bias exists among physicians and other health care providers, and that that implicit bias affects the quality of care they provide to minority patients.

BERWICK: Can you help us understand a little better this implicit bias? So I’m a doctor. A patient comes in, one white, one African-American. What happens in my conscious or subconscious or in the interaction that becomes a generator of the kind of inequity you’re talking about?

WILLIAMS: Great question. What the research shows is that most of us — and this is not about white people, this is about human beings — most of us think that we are driven by our conscious cognitive conditions. In fact, a lot of what we do occurs at a level beyond our conscious awareness and is importantly driven by ideas and narratives and stereotypes that have been deeply embedded in us as part of the culture or the society in which we were raised. There’s a lot of research that indicates that in American culture, African-Americans, for example, are presented as lazy and dangerous and violent. Those are negative characteristics. Health care providers are part of the larger society. Research using the implicit association test, which is one test that tries to get at these unconscious implicit biases, finds that over 70 percent of all Americans have an anti-black bias, and the number for physicians is also over 70 percent, because they’re part of the larger society. We are products of the culture.

So it does not reflect, then, the behavior of bad people. It reflects the behavior of normal Americans who are reflecting the biases and the messages about race that they have received. Importantly, what the research shows is that when we have this negative implicit bias, this negative stereotype, even though we personally are committed to egalitarian principles, without our conscious awareness, when we meet someone who fits that stereotype, we will treat them differently, and honestly will be unaware that we did it, because there was no intent on our part.

And that’s why it’s called unconscious, unthinking discrimination. It’s implicit. It’s not explicit. You are not looking at that person and saying, I’m going to discriminate against them. In fact, if I asked you if you did, you’d say, “I didn’t,” because there was truly no intent. So it’s something that we need to raise awareness levels of. There are a number of strategies that can be used to help clinicians, and all persons become aware of this tendency that we have.

The other point I would say, and this is not just, this is not just about race. Race is very salient. When we meet someone in American society, the research shows, we first put them into social boxes based on age, gender and race. So race is one of three big factors, social factors, that we focus on. But it is a more general phenomenon. If I have implicit biases or negative stereotypes about fat people, about gay people, about old people, about women, those same processes occur.

So I like to tell my students that I am a prejudiced person, because I am a normal human being. And if we are normal human beings, we are prejudiced, because whatever society we were raised in has raised us with negative beliefs about some out-group. Every society has in-groups and out-groups. The question just becomes, who belongs to an out-group in the society in which you were raised? Which means, it might be implicit in my own mind.