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Knowing is not enough; we must apply. Willing is not enough; we must do.
So opens a 764-page report by the Institute of Medicine of the National Academies, released in 2003, detailing racial and ethnic disparities in health care and how to begin to address them. "[B]oth patients and providers can benefit from education[,]" the authors asserted in the report. "The greater burden of education, however, lies with providers."
Early and often, they asserted, health care providers need to be rigorously trained and their progress monitored in order to remove the effects of implicit biases on their medical practice.
The health system is just one area of society where implicit bias is made manifest, but it is the area in which health care and service providers have power to make change, one individual -- and care team, and clinic and organization -- at a time.
Image credit: tupungato for iStock via Thinkstock.
Recognize that implicit bias is a pervasive concern -- and affects how HIV care providers do their work.
"Research for decades by social psychologists indicates that if you hold a negative stereotype about a group in your subconscious mind and you meet someone from that group, you ... will treat them differently," David Williams, Ph.D., M.P.H., a Harvard university-based expert on race, implicit bias and health, said in a recent TED talk.
Williams also gave an electrifying keynote speech on this topic at this year's U.S. Conference on AIDS (USCA) in Washington, D.C. "It's an unconscious process," he said. "It's an automatic process. It is a subtle process, but it's normal and it occurs even among the most well-intentioned individuals."
Public health data indicate that the health effects on African Americans and other people of color are profound: Black people are sicker, and die more quickly, across all socioeconomic, education and insurance levels.
At USCA, a number of sessions addressed implicit bias in HIV care and service delivery. I caught up with several speakers and presenters to get their tips on what steps HIV care providers can take to uncover and remove the harm of bias in their work.
Image credit: Kyle Pompey.
Consider the context in which clients are living and are expected to seek care.
Chair, New Orleans Regional AIDS Planning Council
"We as clinicians, or providers, can get into a mode where we kind of shuffle people along and make people a number, without really caring for the person as a whole. And now, especially in this climate, we have to look at race as a definite strong social determinant for people living with HIV.
"Events in recent years in this country, with the murders of innocent black people by police officers, and even to the current day with what our administration is trying to do with repealing DACA, there is a feeling that race, class and color in this country have proven to be ... not just underserved, but not served -- and even showing to a certain community, particularly the black community, that their lives don't matter. ... How do we serve people that feel that their own government doesn't even value their life?"
Image courtesy of David Armstead.
Physician, heal thyself -- then explore questions of bias openly with your staff.
Lisa Fitzpatrick, M.D., M.P.H.
Senior medical director, D.C. Department of Health Care Finance, Washington, D.C.
"We have to confront our own biases. Once we're comfortable, we can give the space to other people on our teams to do that. It's a bit hypocritical to talk to your staff about addressing bias or exhibiting biased behavior when you haven't. So, I would say that is the first step -- especially doctors because, by nature, I don't think we are introspective people.
"Sit down and take the Harvard implicit bias quiz [an illuminating online test looking at implicit social cognition]. It's probably important to figure out, once you take the test, how do [the results] actually show up in your practice of medicine or in your delivery of health care?
"You have to internalize this stuff before you can expect anybody else to. You can't be a credible person talking about bias when your biases are showing on your sleeve."
Image courtesy of Lisa Fitzpatrick.
Look at your clinic's patient data and start with the outliers.
Marsha Martin, M.D.
Ccoordinator/director, Global Network of Black People working in HIV (GNBPH)
"To a clinician that is managing a clinic or a program administrator looking at their data ... I would ask them: 'Is there anything that surprised you? Anything at all that's come up? Where did the surprise come from?'
"We hear this repeatedly in some of the PrEP [pre-exposure prophylaxis] trials, when the trials are over and people no longer have access to free drugs, and they weren't transitioned and six, nine months later, they're positive -- we've heard that a few times. How did that happen? ... Did you go back to business as usual once the special project was over?
"I would say: Look at what is unique, look at what are the anomalies in your data, look over six months, see what emerges, and then ask: 'How did we miss this? Where is this coming from? Is there something we need to learn in this?' That can be from the clinic director, or the medical director, or a case manager, to say, 'Wow, people are falling through the cracks.'
"And let's not understand the answer as something they did, but a question of, what could we have done differently? Or was there bias in any way?"
Image credit: Olivia G. Ford.
Be open to a challenge.
Mike Weir, M.P.H.
Manager, Policy and Legislative Affairs team, National Alliance of State and Territorial AIDS Directors
"I do think [addressing implicit bias and structural racism in our work] pushes us as professionals. We often get so focused on our work that a challenge is good for us -- I think that type of training really does challenge people.
"At the end of the day, we are gatekeepers: The information that we put out can have a direct impact on individuals' lives. At the end of the day, we serve individuals that are living with HIV and that are impacted by HIV and at risk for HIV -- and remembering the role that we play as gatekeepers is very important."
Image credit: Selfie by Mike Weir.