Structural Racism As A Public Health Crisis Discussion at 2020 Scientific Sessions

Connecticut’s Dr. Keith Churchwell, President Yale New Haven Hospital takes part in the AHA Scientific Session Panel on Structural Racism As A Public Health Crisis.


On Saturday, November 14, a discussion around structural racism as a public health crisis took place during the American Heart Association’s Scientific Sessions.

This Main Event session was moderated by Michelle Albert, M.D., M.P.H., FAHA, Professor in Medicine at the University of California at San Francisco (UCSF) and Director of the Center for the Study of Adversity and Cardiovascular Disease and Donald M. Lloyd-Jones, M.D., Sc.M., FAHA, is currently the Eileen M. Foell Professor at Northwestern University and is president-elect of the American Heart Association (AHA) for FY2020-2021.

The session began with a keynote address by Dr. David Williams, the Florence Sprague Norman and Laura Smart Norman Professor of Public Health and chair of the Department of Social and Behavioral Sciences at the Harvard T.H. Chan School of Public Health.

Dr. Williams began his presentation discussing the fact that compared to whites, African American’s have earlier onset of CHD and its risk and higher mortality of CHD. He discussed the studies focusing on the racial inequalities and how statistically the differences begin with the system.

The inequities overall include the institutions such as schools, early childhood centers, the influences shaping norms and expectations such as high school graduation and economic resources such as income, employment and home ownership, followed by the environmental quality such as air, water soil pollution and hazardous waste sites.

During his keynote he also touched on that at every level of education, race matters. Studies show that white high school dropouts live 3.1 years longer than black high school drop and the gap widens as education increases. African Americans have a lower life expectancy than white with a college degree, than whites with some college, and whites who have finished high school. Dr. Williams goes on to say, “This data profoundly tells us that there is something powerful about income and education that matters for your health”.

Wrapping up his keynote, Dr. Williams discussed the ways we can change these statistics by creating communities of opportunities, eliminating inequities in the receipt of high quality care, and the need to diversify the healthcare workforce to meet the needs of all patients.

The second keynote address was presented by Lisa Cooper, M.D., M.P.H. Dr. Cooper is a Bloomberg Distinguished Professor at the Johns Hopkins Schools of Medicine, Nursing, and Public Health. She is also James F. Fries Professor of Medicine in the Division of General Internal Medicine and a core faculty member in the Welch Center for Prevention, Epidemiology, and Clinical Research.

Dr. Cooper’s address titled; Different America’s Based on Race; Reforming the Science Healthcare Workforce, addressed the current state of diversity in the healthcare workforce, discussed the root causes of the lack of diversity in the sciences and healthcare workforce and potential solutions.

Dr. Cooper stated, diversity leads to a number of important outcomes including improved academic and workforce environments. They lead to organizational and academic excellence and lead to improved access to care and reductions in healthcare disparities. When there is more diversity within the academic or workplace there are better educational experiences and higher ratings of preparedness by learners, more creativity and innovation. Also, it’s been seen that patients and physicians have better communications and higher levels of satisfaction. But due to structural racism we are far from where we need to be to meet this imperative.

One of the reasons we are far from this is because ethnic minorities are underrepresented in academic medicine, racial diversity among practicing health professionals, diversity in hospital leadership is lacking and almost worsening. Leadership and academic medicine also reflect these same low proportions.

The root causes of lack of diversity in science and the healthcare workforce are an individual level and institutional or structural racism. It is found that black/African American leaders at academic medical centers report isolation, disrespect, overt and covert bias, devaluing of research regarding community health and added responsibility of leading diversity efforts for which they receive little or no credit toward advancement.

These bias-based experiences make it difficult to achieve excellence according to standard leadership expectations and some fear that articulating their concerns will limit their advancement, or even lead to termination. This has an impact on the mental and social well-being of faculty.

In conclusion, Dr. Cooper stated that although many challenges remain regarding achieving racial parity in the science and healthcare workforce, several opportunities exist to address these challenges and that diversity inclusion, equity belonging are everyone’s responsibility.

Following the keynote address, a panel discussion moderated by Dr. Albert took place covering the topic of structural racism in our work environment – personal racism and what practical strategies do you use to change the narrative.

Panelists including Dr. Albert

The panelists included

  • Keith B. Churchwell, M.D. cardiologist and president, Yale New Haven Hospital and senior author of the AHA Presidential Advisory
  • Paula A. Johnson, M.D.- cardiologist and researcher in health disparities and President Wellesley college
  • Ted W. Love, M.D., cardiologist, and pharmaceutical executive
  • Sonia Y. Angell, M.D. -internist and leader in public health recently leadership roles in DPH in NYC and state of CA
  • Hannah A. Valentine, M.D., cardiologist, and recently chief officer of scientific workforce diversity at the national institutes of health

The first answer came from Dr. Angell. She found where she works in the public health environment, the places she hears the narrative is in the community. When working with individuals in the community, she tries to understand what the challenges are and her responds vary depending on who she is speaking with. She does find that the first thing to do is listen and find out why it’s happening. From a public health perspective, she believes you should use evidence and start from data to find common understanding. Talk to people about where we are and how did we get to that place. Take if from personal to structural.

Dr. Love  believes you should first acknowledge that segregation is a key problem. Until we get beyond segregation, we will have an uphill battle. From the corporate side Dr. Love said he focuses on investment. He believes that a budget is a moral document. He states that when you look at the NIH budget, during the 80’s and 90’s, the amount spent on Cystic Fibrosis research compared to sickle cell disease is 100,000 to 1. The people who make decision on how to invest the dollars are not focusing on Sickle Cell disease as they are on other diseases, so investment becomes a big issue. Lastly building trust is critical.

Dr. Churchwell says from the standpoint of leading an institution, delivering care within the local communities, investment has to be more around the patients served and thinking about their overall continuity of care for them. Understanding that mission can be a true investment in that overall margin. Understanding how we follow that patient in their overall journey to better health and understanding their true needs around that is incredibly important. Breaking down the appropriate barriers both at the local level and regional level that needs to be done is incredibly important and thinking through how we make our population we serve healthier.

Dr. Keith Churchwell

Dr. Johnson beings by saying, in education we have to recognize both our students and institutions are products of our society. For the institution it is about the questions asked and the work done to lead to the ability for everyone at college to flourish. That includes students, faculty as well as staff. How do we do this from a data driven and evidence-based perspective? This is everything from the classroom, residential life, to internships. As we think about these institutional barriers we think about faculty – rethinking mentoring and support not in a way that says to a student you are lesser than, but to an institution what is it that we need to do to embrace change. It’s going to take us a long time to move forward in a way that is powerful and ensuring that this conversation is not the only conversation but that we are moving that work forward consistently.

Dr. Valentine states that the way we communicate these issues is critical to make the change we want. View that situation as an opportunity for conversation and an opportunity for education of like the fantastic data that has been shared during this panel. It’s our duty to communicate it in a way that others can understand it and internalize it. You should talk to them about the different forms of racism and draw on  analogies and the community in a straightforward way.  Also, share personal information in a way people can understand it and point to the multiple barriers and tell them to look into their environment and in the mirror and see why it is that in their leadership is not more diverse.

As a wrap up to the session, specific panelists were asked how they have addresses structural racism or how they have learned about structural health.

Dr. Johnson referred back to the studies that show that the future of education and projected population of black college ready students is projected to decrease out of proportion. So, it is essential to broaden that pipeline.

Dr. Valentine believes there are four areas where we need work – the workforce where we need to continue to work on the education pipeline. Funding process where there has clearly been a gap in the award rates for independent grants. The third area is funding health disparities – this is the area where we find more black and people of color and it is important to fund research that explains the way this chronic effect of racism affects the health of all of us. Finally, looking in the mirror and making sure the policies and procedures that we recommend for others are being adopted for our own institutions.

Dr. Churchwell was asked the question; a recent perspective outlined practices that healthcare systems can do to dismantle structural racism including divesting from tiered health insurance and mandating measurable health outcomes. How might healthcare leadership such as yourself achieve these goals while growing the financial health of your organization?

Dr. Churchwell responded that one of the activities they have been working on at Yale is talking to the payers – not the insurance companies, but also the employers, to make their workforce healthier. From the federal perspective there is more of a stop gap in regard to how they think about delivery of care. He states that at Yale “we’ve dipped our toe in this particular broad ocean” – and asked themselves are they going to actually have those funds available and how they are going to use them to best serve the population.  They have put together a consortium to build an institution which is modern from the patients perspective and also make it multi-disciplinary to deliver care and ancillary needs that are for the population they serve, such as mental health, pharmaceuticals and looking at the local environment to make them healthier and help them decrease the funds they are losing and the financial health system for the patients that they serve.

Dr. Angell was asked what some of the key lessons learned about structural health. Dr Angell responded saying “we need to make sure we have diverse representation in the workplace. We need those people at the table. There is a difference between discussing the outcome and those who created them. We need to work with urgency.”

For the last question of the session, Dr. Love was asked, in recent years we ‘ve seen industry CEO’s increasing using their pulpit for activism. How have you thought through when and how to drive the anti-racism conversation? Dr. Love responded saying he sees corporations as citizens and that we really have to operate with the belief that we are trying to help our country to become better and stronger at getting things done. Getting our workforce to get engaged is very important. We are doing that here and we are part of the solution. We need to try and make this a better country for everyone.