The deaths of Alton Sterling and Philando Castile in July 2016 reverberated throughout the medical department at Brigham and Women’s Hospital (BWH), destabilizing daily routines in the new academic year. The momentum for change had been building since the Black Lives Matter movement made national headlines in 2013. Our internal medicine residents urged us as a department and institution to reinvigorate the long but essential process of recognizing racism in our environment and to act to remedy it. They said the issues the Black Lives Matter movement made visible were not external or separate from our experiences at an academic medical center. Structural racism, discriminatory policing and criminalization of black people affect health care. These long-standing issues reflect the living legacy of our country’s history of racial discrimination and its many tragic consequences, including the Native American genocide, slavery, Jim Crow laws and eugenics. The question asked was simple: “What are we going to do?”1
Leading action on health justice issues has been a long-standing challenge for health professionals, who are often more comfortable with descriptive research as the primary focus of intervention. In our department, the Black Lives Matter movement has created a window of opportunity for open critique of current inequalities in health care practices and direct conversations about structural racism. Residents and faculty called for hospital-wide communications that clearly state our values, mandatory implicit bias training for all hospital staff and faculty, visible solidarity with patients and staff immigrants, a more welcoming environment for all patients and employees and commitments to racial and ethnic discrimination. , gender and other forms of diversity. Calls for platforms to bring together and coordinate efforts across the facility have been met with actions from hospital and department heads who have recognized the need for change. Health equity and social justice committees at several institutional levels have been revived with the support of key hospital leaders. Some of these groups had previously been convened in times of social change, but disbanded when the fervor waned.
We launched the “new” BWH Department of Medicine Health Equity Committee in early 2017 to advance action on health equity and engage new partners across institutions and disciplines. We have endeavored to ground our work in history and critical theory. We have partnered with the Southern Jamaica Plain Health Center (SJPHC) – a community health center, an established leader in racial justice and part of our hospital network – and the Institute for Healthcare Improvement (IHI ), which launched a collaborative learning program to advance racial justice in health care. Experienced SJPHC leaders pushed our committee to define the term “racism,” to name it explicitly, and to educate us on the long history of racism in medicine.2 Our partners at IHI have encouraged us to build on the existing institutional change infrastructure created as part of the patient safety movement. To optimally focus our attention and begin effecting change, however, we needed a well-defined issue that exposed the institutional racism within our walls.
Rather than starting from scratch, we looked at the history of our institution. We drew on critical race theory to begin with the assumption that racism is part of everyday life.3 With this hypothesis in mind, the new committee’s house of internal medicine staff focused on their observation of potential racial differences in admissions of cardiology patients to the cardiology ward rather than the general medicine ward. A previous iteration of the committee investigated racial inequities in cardiovascular care at our facility 10 years earlier. Our committee agreed that it was time to resurrect the data from this survey, update it, and use the process to raise awareness of racial inequities in health care at our facility.
To solve this problem, we needed new data, support from multiple departments and divisions, resources and commitments to implement projects to correct identified inequities. Above all, we had to develop the courage and political will to speak about a historically uncomfortable topic in a predominantly white institution. House staff played an essential role in moving the project forward. Our partnership with SJPHC and IHI has created a coalition of physicians, nurses, social workers, administrators, and others who have built a common understanding of the issue across our facility. Our goal was not to create a new social movement, but rather to learn from the Black Lives Matter movement and create institutional change by merging strategies and tactics from inside and outside the institution and using top-down and bottom-up approaches.
The learning and knowledge generation that takes place in academic medical centers has generally not been extended to include issues of racism and racial inequality. To address this gap, SJPHC created a program called Adaptive Leaders for Racial Justice, which aims to prepare clinicians to challenge prevailing beliefs about the causes and solutions to racial inequities in health. Several faculty members and residents of our Health Equity Committee have participated in this program and have become spokespersons for racial justice as well as formal and informal teachers on these issues.
Naming racism was one of the committee’s most important tasks, and that challenge was sometimes met with defensiveness or silence. When our heart failure study demonstrated that black and Latino patients were consistently less likely to be admitted to the cardiology specialty ward than white patients, our committee recognized this finding as an example of institutional racism; however, it was difficult to reach consensus on this key issue.4 “Institutional racism” is defined as differential access to societal goods, services and opportunities based on race.2 When we shared this definition, faculty members who had initially shown resistance began to recognize the ways in which racism was present in the daily practices of our institution and throughout society. Not all professors agreed with this definition of the problem, but a critical mass advanced despite the resistance. After much conversation and debate, the concept of institutional racism was no longer remote, abstract, or someone else’s problem. As a result, our department funded two projects with the goal of addressing the inequities discovered in heart failure care. One project is to survey physicians to elucidate the drivers of admission decisions; the other aims to improve the quality of management of heart failure in the general medicine department.
Physicians must engage in social movements if we hope to contribute meaningfully to improving health by addressing its social and structural determinants. We must proceed with caution, however, because our profession has not always supported social movements, as the history of the American Medical Association and the civil rights movement illustrates.5
In fact, our clinical training has the potential to create a mindset that directly conflicts with the views held by social movements. Clinical training creates a state of mind of urgency; a focus on short-term goals and on repair and healing; an expert identity, sometimes with disgust at being challenged; and risk aversion. These attributes are, for the most part, necessary and desirable among clinicians, but they can be counterproductive in the context of social movements. The social transformation sought by the movements requires a long-term vision, the building of power to enact change over time rather than the implementation of quick fixes, humility, a willingness to take risks despite the uncertainty and a learning mindset.
Our experience shows that institutional change in health care is possible. We are moving towards becoming an anti-racist institution; however, it’s easy to lose momentum when attention and headlines shift to other pressing issues. Such a loss of momentum most likely led to the withering of earlier institutional efforts related to racial equity. Capitalizing on the urgency generated by the Black Lives Matter movement was a powerful strategy to align interests and focus attention on a large, often slow-to-change institution. Unfortunately, the recent murder of George Floyd demonstrated the persistence of structural racism.
The next frontier for health justice in our institution is that of structural and political change. Addressing these challenges will require the continued and expanded engagement of institutional leaders to directly address the ways in which racial inequities in health are structurally produced. In the words of renowned author Ibram X. Kendi, “There are only two reasons for racial inequality: the politicians or the people.” We strongly believe that it is policies that create inequalities, however unintended, and we will continue to push forward actions in our institution to change them.