Abstract
The U.S. public health system has been challenged in constructive ways over the past year, from fighting a novel virus to managing the resulting pandemic, and surmounting pressure from the general public to reconcile past and present trauma fueled by health and racial inequities that claim lives and perpetuate physical, mental, and emotional harm in predominantly Black, Indigenous, and other non-white communities. Through term definitions, discussion of the current literature, and content expert opinions, this article reveals the casual yet calculated manner in which unconscious bias saturates health care and the governing public health systems in the United States, and presents a call to action for professionals in the public health field to keep racial and health equity at the forefront of solutions to the “wicked problems” faced in this field.
The year 2020 brought buzzwords, terms, and concepts that were new for some and a painful reminder of generations of inaction for non-white communities. Unconscious bias and public health are two of the terms that made headlines in 2020. While both terms have been spoken about in their own regard for decades, the past year brought their intertwined, nuanced, and longstanding complicated relationship into focus for many across the United States and the world for the first time. In an effort to better understand the work that lies ahead for health professionals, this article highlights the damaging effects of unconscious bias on the health and well-being of communities in the United States and poses a way forward for all health professionals looking to build trust, mutual respect, and real and enduring partnerships in their professional relationships with Black, Indigenous, and other non-white communities.
What is Public Health?
In 1922, scholar J. Howard Beard wrote, “Public health work is as old as history” (in Truglio-Londrigan & Lewenson, 2013, p. 4). Two definitions of public health have stood the test of time and continue to age with grace and accuracy. C.E.A. Winslow, a prominent public health leader in the early 20th century, defined public health as “the science and art of preventing disease, prolonging life, and promoting health through the organized efforts and informed choices of society, organizations, public and private communities, and individuals [combined with] the development of social machinery [structures] which will ensure to every individual in the community a standard of living adequate for the maintenance of health” (in Truglio-Londrigan & Lewenson, 2013, p. 4). The second, widely used definition, from the Institute of Medicine's (IOM) report, The Future of Public Health, is: “what we, as a society, do collectively to assure the conditions in which people can be healthy” (IOM, 1988, p. 1).
Both definitions remain relevant when discussing the health care, transportation, educational, financial, political, and social structures that make up the public health infrastructure we know today. Few people outside the field realize that public health encompasses all of these sectors as well as many of the industries they come into contact with on a daily basis. Each sector and industry plays a role in preventing disease, promoting the health and well-being of communities, and enhancing overall standards of health. In this article, the term public health refers to health-care infrastructure set up to support the physical wellbeing of individuals, families, communities, and populations.
What is Unconscious Bias?
The term unconscious bias was derived from the theory of aversive racism introduced by Gaertner and Dovidio (1986). Unconscious bias refers to an individual's ability to form negative unconscious and/or automatic feelings and beliefs about other individuals and groups of people that may differ from their conscious and external attitudes (Gaertner & Dovidio, 1986). According to Hall et al. (2015), unlike explicit biases, which include attitudes, beliefs, thoughts, and feelings that an individual is aware of, deliberately thinks, and can consciously report on, unconscious biases are thoughts, beliefs, and attitudes that exist outside of an individual's conscious awareness. In summary, unconscious bias triggers specific human behavior without awareness, making it difficult for one to actively acknowledge its presence.
From birth, we are being primed with thoughts and ideas which solidify into narratives, which are used to form policies which serve the dominant group; the end result is structural racism.
What is Racism?
The terms unconscious bias and racism are often used interchangeably. Despite this overlap that happens in common speech, it is important to understand how these two terms differ.
In order to define racism, it is pertinent to understand the terms prejudice and discrimination. Prejudice is “a preconceived or assumed negative ideology toward a person or group based exclusively on the person's membership in a defined social group/community” (Hardeman, 2018, slide 15). Discrimination is “the treatment [of people] that is rooted in prejudiced ideology” (Hardeman, 2018, slide 17). In other words, prejudice is a thought, feeling, or belief, while discrimination is the action that comes from prejudice.
According to Hardeman, racism involves both prejudice and discrimination, because it includes “the dynamic of power to enforce one's prejudice and discriminatory practices through structures that uphold racist institutions” (2018, slide 18). While both unconscious bias and racism require prejudicial beliefs and attitudes, they differ in that unconscious bias implies that an individual is, at the moment, unaware or unconscious of the prejudicial ideology they hold, while in the case of racism, this prejudicial ideology is backed by discriminatory actions and power. In other words, racism is explicit. Dr. Jokho Farah, Co-Chair of the Minnesota Department of Health's Health Equity Advisory Leadership Council, states:
Unconscious bias creates societal structures that allow racism to thrive. From birth, you are being primed with thoughts and ideas which are solidified into guiding narratives, and those narratives are used to form policies which serve the dominant group. The end result of this process is structural racism. The relationship is cyclical; unconscious bias is a feedback loop for racism. We have to figure out what the disrupters of that feedback loop are that will stop the cycle from continuing and interrupt the transmission of trauma to present and future generations. (J. Farah, personal communication, January 13, 2021)
Moving forward with this understanding that unconscious bias is not the absence of racism but rather a driver of racism leaves many in the public health field searching for the ways in which unconscious bias impacts their field.
The Intersection of Unconscious Bias, Public Health, and the Health-Care System
The detrimental effect of unconscious bias in the medical field is not a new finding. In 2003, the IOM published Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare, a report highlighting the fact that unconscious bias against members of particular racial and ethnic social groups could affect the quality of care and communication provided to them. Twelve years after that groundbreaking IOM report, Hall et al. (2015) published a systematic review of the literature on racial/ethnic bias among health-care professionals and its influence on health-care outcomes. This review revealed that of the 15 studies included, 14 contained significant evidence of health-care providers displaying low to moderate levels of unconscious bias against their non-white patients (Hall et al., 2015). Furthermore, 13 of the studies found that white health-care providers were more likely than their non-white counterparts to associate negative words with Black Americans; four studies found that health-care professionals identified Black Americans as being “less cooperative, less compliant, and less responsible in a medical context” than their white counterparts (p. e71). These publications make clear that unconscious bias exists within the U.S. health-care system.
A Critical Look at how Bias Plays Out
The 2003 IOM Unequal Treatment report inspired medical professionals and researchers to explore the myriad ways in which unconscious bias is integrated into the health-care system and how it causes harm. As researchers study the why, they are finding that it is equally important to bring light to the patient's experience with the medical provider, including the patient's perception of the quality of care they are receiving, the provider's use of patronizing language, and the patients ‘past experiences with discrimination (DeAngelis, 2019; Hall et al., 2015).
According to a study by Hagiwara et al. (2013), care providers with higher implicit bias test scores failed to provide space in conversations for their patients to speak than their peers with lower implicit bias test scores. This finding aligns with a study by Cooper et al. (2012) in which medical providers with high implicit bias scores were more likely to monopolize conversations with Black patients, which in turn was associated with those patients ‘lack of confidence in providers and low perception of quality care.
Similarly, the systematic review by Hall et al. (2015) highlighted the fact that Black and Latino patients perceived lower-quality interactions with health-care providers who demonstrated higher levels of unconscious bias. Patient-centeredness, patient–provider communication, and contextual knowledge of the patient were cited in the review as domains in which Black patients perceived poor treatment when interfacing with the health-care system. The review concluded that health care providers with “anti-Black bias” (p. e72) frequently exhibited aggressive communication styles, rejected opportunities to work collaboratively with Black patients, and frequently exhibited verbal dominance during interactions with Black patients.
In addition to direct occurrences of unconscious bias, indirect forms of unconscious bias have also been shown to impact the wellbeing of non-white communities. A 2019 systematic review by Marcelin et al. revealed significant evidence of members of medical school admission committees displaying unconscious preference for white male candidates, despite acknowledging no explicit preferences for white candidates. The review also revealed that racial minorities in cohorts of medical residents suffered micro-aggressions and discrimination from peers and faculty, as well as the burden of being tasked as “ambassadors” for the race whenever harmful or stereotypical tropes were mentioned (Marcelin et al., 2019). These experiences were highlighted as specific ways in which unconscious bias can affect the lived experiences of medical trainees who identify as racial minorities and reduce the number of non-white providers practicing in the health-care field (Marcelin et al., 2019)
Members of the public health field must move to action in a way that is conscious, efficient, acknowledges past harms, and works to eliminate the malpractice influenced by bias that is based in harmful narratives related to race and ethnicity.
Confronting Bias in the Field
When confronted with the knowledge of how bias intersects with public health and the health-care system, some are left confused about how to intercede. According to Deputy County Manager — Health and Wellness, and former Director of Public Health, Kathy Hedin, this was the case for St.Paul-Ramsey County's Public Health Department (SPRCPH) up until a decision to include a focus on advancing health and racial equity in their strategic plan was made in 2013. This historic move ushered in system-wide learnings about the impact of racial and health inequities on their workforce and the community at large (K. Hedin, personal communication, January 28, 2021). Four years into their journey toward health and racial equity, the public health department had all 365 staff members complete the Intercultural Development Inventory (IDI) process, an assessment of intercultural competence and bias (IDI, 2021), in an effort to take a focused look at how their thinking around racial equity and health disparities plays into their work with families and community members, and to enhance their understanding of cultural competency while also identifying their own knowledge and performance gaps (K. Hedin, personal communication, January 28, 2021). The results of this process have paved the way for innovative, insightful, and effective personal and professional development throughout the department. Since the inception of these efforts, SPRCPH has instituted a Racial Health Equity Leadership Team that provides guidance on the implementation of racial and health equity work, hired county-wide and department-wide Racial and Health Equity Administrators, and championed the inclusion of a priority focus on racial and health equity in the county-wide strategic plan (K. Hedin, personal communication, January 28, 2021). What began as an opportunity to enhance the department's collective cultural competency and address unconscious bias became the guiding star in their work to create an organizational culture that fostered collective awareness of the existence and ramifications of bias and activated people throughout the organization to reduce harm to Black, Indigenous, and People of Color communities.
Providers with high implicit bias scores were more likely to monopolize conversations with Black patients.
Missing the Mark
Despite the knowledge generated since the publication of Unequal Treatment (IOM, 2003), the public health field is embarrassingly behind in its work of discovering and eliminating unconscious bias. Vayong Moua, Director of Racial and Health Equity Advocacy at Blue Cross Blue Shield of Minnesota, spoke of the frequent and direct ways in which unconscious bias goes unchecked in physicians ‘offices and in boardrooms filled with premier public health and health equity experts.
There is both unconscious and conscious bias in the act of determining what is considered valid public health knowledge. What is legitimate information? If you want a citation for structural racism I can give you an academic piece or my grandmother's experience. There is an unconscious bias that diminishes the lived experiences of people and that undermines racial equity. The reality of our communities who face racism in their daily life is diminished. (V. Moua, personal communication, January 21, 2021)
Director Moua points out something known in the field of public health but seldom acknowledged: Unconscious bias keeps the field stagnant, resistant to change, and walking a fine line between hypocrisy and integrity. This bias creates a false sense of scientific rigor that, when overlaid with decision-making power, fuels structural racism.
Imperatives for Moving Forward
Now more than ever, we live in a world in which calls to action are made with urgency and frequency; this appears to be due to a growing shared consciousness, and we are better for it. It is imperative that on this continued journey towards health and racial equity, members of the public health field move to action in a way that is conscious and efficient, acknowledges past harms, and works to eliminate the malpractice influenced by bias that is based in harmful narratives related to race and ethnicity. From supporting research that addresses this evolving topic; to enacting policy that makes continuous unconscious bias training and reflection part of the public health curriculum; and championing work cultures that affirm equity, diversity, inclusion, and acceptance, there are specific lanes for each of us in this work, and they all start with seeing the communities we care for as the stakeholders and subject matter experts they are.
Footnotes
Disclosure. The authors have no relevant financial interest or affiliations with any commercial interests related to the subjects discussed within this article.
Funding. The author(s) received no specific grant or financial support for the research, authorship, and/or publication of this article.
Abiola Abu-Bakr, DNP, RN, MPH, PHN, is an Advanced Practice Public Health Nurse and Doula with a passion for promoting racial and health equity in both her local and global communities. Dr. Abu-Bakr is a firm believer that everyone should be equipped with the knowledge and resources to live a healthy life.