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Healthcare bias has to be addressed to protect people of colour during this coronavirus crisis

From representative to structural bias, we must be aware how these things effect both patients and healthcare staff

Pragya Agarwal
Sunday 29 March 2020 17:53 BST
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Related video: NHS staff conduct Covid-19 tests at Chessington drive-through centre
Related video: NHS staff conduct Covid-19 tests at Chessington drive-through centre (Getty)

Kayla Williams, a 36 year old woman, died of suspected coronavirus in London last week. Her husband says that he was told that the hospital wouldn't take her as "she was not a priority" although documents confirmed that paramedics were treating it as a serious coronavirus case. Kayla was a black mother of three young children.

This tragic case raises concerns to me about how subversive racism and implicit bias is likely to affect minority ethnic communities during this pandemic.

Medical professionals are human. They are also under a lot of stress, especially now more than ever and working tirelessly against all odds. They are, therefore, not immune to falling back on their racial bias. While working on my book Sway: Unravelling Unconscious Bias, I have found numerous studies that show how people of colour can face differential treatment by medical and healthcare professionals, and that unconscious bias can cause a lack of adequate and timely treatment.

Research shows that most physicians already have in mind two or three possible diagnoses within minutes of meeting a patient, and that they can develop these hunches from very incomplete information. The doctors are relying on shortcuts and rules of thumb – heuristics – to make such decisions, especially when they are under time-pressures.

They can fall back on representative bias, where they are influenced by what is "typically" true. In doing so, they can fail to consider other possibilities that contradict their mental templates of an illness. When people are confronted with uncertainty – the situation of every doctor attempting to diagnose a patient – they are susceptible to unconscious emotions and personal biases.

There is plenty of evidence to show that race and ethnicity can affect the treatment a patient receives. For instance, race and sex have been shown to play a role in the treatment of patients with cardiovascular diseases. Research from Nina Martin and Renee Montagne in 2017 showed that a black woman is 22 per cent more likely to die of heart disease than a white woman. Black women also have a higher mortality rate in childbirth even though there is no evidence that they are more likely to suffer from complications.

The most recent stats indicate that black women are 71 per cent more likely to suffer from cervical cancer-related death, and 243 per cent more likely to die of complications in pregnancy and childbirth. In sub-Saharan Africa maternal mortality rates are dropping, while in the US they have steadily risen for minority ethnic women between 2000 and 2014.

According to the American Cancer Society, the incidence of breast cancer in African-American women is slightly lower than in white women but their mortality rates are higher. There have been stories reported of black women having experienced poor treatment, such as physicians not taking the time to explain their diagnosis and options and a lack of support in dealing with complications. The disparity in survival rate is largely attributed to later-stage detection among black women.

Black patients can receive less pain relief than white patients. This bias in perception of pain, and errors in treatment recommendation of pain, are also associated with a racial bias. A scientific study from 2016 shows that there also exists a false belief about biological differences between black people and white people, such as that black people’s skin is thicker than white people’s skin or that black people are biologically stronger than white people or that black people’s blood coagulates more quickly than white people’s blood.

A study examining pain management among patients with metastatic cancer found that only 35 percent of minority ethnic patients received the appropriate prescriptions – in accordance with the World Health Organisation guidelines – compared with 50 per cent of non-minority patients.

There is not enough evidence to show that these biases stem from underlying racist beliefs, as racial disparity in pain perception has not shown a direct correlation with racist attitudes. However, those ideas have historical precedent - they were used to justify slavery. In the 19th century, prominent physicians sought to establish the ‘physical peculiarities’ of black people (such as thicker skulls and less sensitive nervous systems) that could ‘distinguish him from the white man’. Other physicians believed that black individuals could tolerate surgical operations with little if any pain at all.

Extensive research has now been conducted in the US into racial bias in healthcare, but this is an issue that is still underreported in the UK. Much of the research pertaining to the NHS has been focused on the treatment of black and minority ethnic (BME) doctors (which is equally crucial to understand) rather than patient experience.

As far back as 2003, the then chairman of the Commission for Racial Equality, Trevor Phillips, said that the NHS was a prime example of "snow capping", where the organisational pyramid is white at the top and black at the bottom. Unconscious bias will affect both NHS staff and patients, yet it is a topic that we still tiptoe around.

Michael Gove asked if coronavirus has made the Tories regret underfunding the NHS

There is also a possibility that people of colour do not feel as comfortable seeking help when they are ill because of the fear of being discriminated against. When people believe that they would be discriminated against, or that they do not deserve a similar treatment as other people in society, they do not focus on themselves because they believe that they are not worth it – a materialisation of ingrained racial marginalisation.

Cultural background can also prevent people from even reporting the pain and discomfort appropriately. Some cultures are believed to be more stoic than others. In addition, there is an inherent design bias since, as Mary Narayan wrote in the Journal of Nursing in 2019, the assessment of pain scales can be culture-dependent.

For instance, a horizontal numeric pain scale may be confusing for someone of Chinese background because Chinese language is traditionally written and read vertically. This can stop them from understanding and interpreting the scale and therefore responding inaccurately, which in turn can affect the physician’s diagnosis of the seriousness of their condition and hence the treatment.

This means that it is crucial that we take this into account while collecting data, but also while providing support and information to the communities. Disparities in access to healthcare, location of healthcare services, and support following any diagnosis and treatment are all part of broader structural racial inequality.

During times of crisis and fear, our biases are heightened and so it is likely that implicit racial biases are stronger than ever. We must absolutely make sure that people of colour are never treated as "not a priority" during this pandemic.

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