I have dedicated my career to working with Philadelphia families who are underserved by the educational, medical, and political institutions that are supposed to help them. At our pediatric clinic in North Philadelphia, most of my patients are children of color. More than 90% of our families rely on Medicaid.
Many reside in neighborhoods so deeply impacted by structural inequalities that average life expectancy is as much as 20 years less than that of more affluent areas. Every day, I am in awe of the beauty and resiliency of the families we care for, and the richness of lives that belie and defy any statistics.
As part of a research project at our institution, I recently took the Skin-Tone Implicit Bias Test (IBT), developed at Harvard in 1998 as part of its Project Implicit program to detect all kinds of biases. It has also been used as a training tool at police departments and private businesses such as Starbucks after episodes of potential racial profiling.
An implicit bias is any set of associations we have about a group of people but aren’t aware of. The IBT doesn’t use obvious questions to figure this out. Instead, it measures how quickly the test-taker reacts to cues. For example, the test may ask the participant to click on the word “good” whenever an image of a black face is shown and click on the word “bad” whenever a white face is shown. Then the exercise is done in reverse.
(If you’d like to learn more about the phenomenon of implicit bias, I highly recommend a powerful Ted Talk by Dushaw Hockett, executive director of Safe Places for the Advancement of Community and Equity.)
My own test results shocked me.
I learned that I have an unconscious preference for people who look like me, a white man. The results contradict everything I believe. They were painful to see. But they have made me more conscious of my unconscious preference for white faces in this test.
Most people who take the test are implicitly biased. That does not mean they are racist — racism is anything but implicit.
It wouldn’t be surprising to learn that people feel more inclined toward those who look more familiar. But here’s the even more disturbing part: The preference for white faces many times also holds for test-takers of color.
And health-care professionals are no different, as a 2018 review of multiple research studies in the journal Pediatrics demonstrated.
A study of preschoolers, published this year in Developmental Science, showed that 4-year-old children, both black and white, rated images of white children more positively than those showing children of color. This pattern of racial bias was consistent for both black and white children who participated.
Some have named racism a “socially transmitted disease,” in the sense that racism is taught, it’s passed down, it’s contagious.
Race has no real basis in genetics — there are no clear genetic boundaries based on race, and making health predictions according to race is an issue of probability. Race does have incredible implications for health outcomes. But those implications are based on social issues, not biology.
In 2003 the Institute of Medicine published “Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare,” 764 scathing pages concluding that “race and ethnicity remain significant predictors of the quality of health care received.”
Racism in medicine is a historical fact. There is the Tuskegee experiment that allowed black men with syphilis to become ill and die 27 years after the discovery of penicillin that could have treated them. Birth control pills were tested on Puerto Rican women in the 1950s without proper consent. The cervical cancer cells of Henrietta Lacks, a black woman in Baltimore, were used in cancer research without her consent (and continue to be used).
The city of Philadelphia’s recent report on the health of our city revealed that black children were three times more likely than whites to die before their first birthday. Structural racism surely has its hand in this and other health disparities in our own backyard.
In August, the American Academy of Pediatrics (AAP) published “The Impact of Racism on Child and Adolescent Health.” Among the findings in this courageous statement:
Some specific examples of racism in pediatrics include a 2018 report that showed that children of color who were brought to 18 emergency rooms across the country with head trauma were twice as likely to be evaluated for abuse than were white children. Several other studies showed that children of color were less likely to receive pain medicine even when suffering from appendicitis — this is an unfortunate example of how some people still believe the myth that black people aren’t as sensitive to pain as whites.
Children experience the results of structural racism in the condition of their neighborhoods, the quality of their schools, and the kinds of opportunities that come their way. They witness people who look like them experiencing racism in person and on screens. Left unchallenged, racism can cause a child’s stress response to be on high alert. Over time, that state can harm a child’s developing brain and body.
The AAP report challenges our profession to confront racism in our field. It challenges us to address biases in health care, in the educational system, in our justice system. It guides us to help buffer the effects of racism both blatant and vicarious. It tasks us to develop a more diverse and culturally humble workforce. It charges us to acknowledge and address implicit bias.
I have taken the first steps by understanding my own unconscious bias in a more informed and open way. Will you?