PracticalDermatology

Black Americans die at higher rates than their white counterparts from heart disease, cancer, stroke, diabetes, kidney disease, and maternal-fetal death. At the current rate of roughly one premature death of a black person every 7 minutes, the US sees 200 Black people die prematurely every day.¹

The American Medical Association (AMA) has recognized racism as a public health threat and committed to actively work on dismantling racist policies and practices across all of health care. In policy adopted in 2020, AMA prescribes steps to combat racism, including: 1.) acknowledging the harm caused by racism and unconscious bias within medical research and health care; 2.) identifying tactics to counter racism and mitigate its health effects; 3.) encouraging medical education curricula to promote a greater understanding of the topic; 4.) supporting external policy development and funding for researching racism’s health risks and damages; and 5.) working to prevent influences of racism and bias in health technology innovation.

Racism’s pernicious effects influence dermatologists in terms of the ways we treat patients, interact with our peers, and even lead and succeed within this specialty. Increasingly, dermatologists are taking stock of the unique needs of patients of all skin tones and confronting the lack of diversity—in research, education, pharmaceutical advertising and hiring practices, and more—that has existed in medicine generally and our specialty specifically for generations. As a result, the care that we provide to patients is improving. But there is much more to be done.

In order to better serve patients and advance our specialty, it is important for all dermatologists to be aware of the needs of individuals across all racial, ethnic, and cultural backgrounds. We must think about the whole human person in front of us and emphasize treatment of the patient and not just a wrinkle, a rash, or a skin cancer. We must also be cognizant of the ways that our behavior can either improve or complicate the experiences of our patients, peers, family, friends, and neighbors.

My Perspective

As an African-American dermatologist, I must deal with the notion that my privilege does not shield me from bias and discrimination. My mother is a practicing pediatrician. Her father was a dentist during the roaring days of Harlem. One of my lifelong goals is to continue the work of my ancestors, fulfill my own dreams, and continue to fight against systems that work to prevent other skin of color and marginalized people from getting to where I am and further. Tyler Perry recently said we have to, “meet each person at their humanity and refuse hate.” My mission in my practice and in life is to recognize the humanity of every person, regardless of skin color, that comes through the door. Adopting this simple approach can avoid many problems in medicine.

Racial Disparities in Health care

Research increasingly shows the ways that persistent racism continues to impact people of color in all aspects of life. Systemic racism describes the ways in which racism has influenced various aspects of our society, including our social, educational, employment, and health care systems. While we may be making progress (though arguably not quickly enough), the long-term effects of systemic racism persist. Health disparities have emerged as a clear example.

Published nearly 20 years ago, “Unequal Treatment” is a report from the National Academies’ Institute of Medicine that clearly identified systemic racism as a key contributor to health disparities. The report ranked the detrimental health effects of systemic racism above the impacts of poverty, lack of healthcare access, and other social factors.

Data indicate that one’s ZIP code could be a greater predictor of life expectancy than one’s genetic code. The Robert Wood Johnson Foundation provides an interactive search that helps demonstrate the point. I practice in New Jersey where the wealthiest county, Hunterdon, is 91% white. The poorest county, Cumberland, is 63% white. While the average life expectancy for the state is 79.8 years, it is 83.4 years for Hunterdon County and only 75.36 for Cumberland County. Residents of the less diverse, more affluent county exceed average life expectancy, while residents of the more diverse, poorer county of the same state are dying younger.

No doubt a variety of factors contributes to this disparity, including income, occupation and related exposures, proximity to advanced health care, and more. But even these factors may at least indirectly correlate with race. Access to the best schools and medical care is linked to where you live. Even access to supermarkets and fresh fruits and vegetables can be impacted by your ZIP code. (Read “Workplace Diversity: Spotting Opportunities and Overcoming Challenges.”)

Importantly, these factors can be modified, if not immediately, then over time. As physicians, we must facilitate true partnership with patients. We must avoid any assumptions about our patients and take the time to ask the right questions and provide reasonable solutions. Just because the patient is in your office does not mean the patient is a resident of the local community or that he or she experiences the community as you do. Think both about your practice and your behavior, as well as the individuals you treat.

Do you show—actually demonstrate with your body language—that you listen to patients and are willing to be their partner in care? Do you demonstrate cultural sensitivity and provide a space that is inviting to people of diverse backgrounds? Do you ask questions of all patients about prescription drug coverage and whether it will cover the drug you are prescribing? If not, is there an alternative? Is the patient not using their medication because they don’t like the base or is it possible they did not refill a prescription they cannot afford? Is the OTC or cosmeceutical you are recommending something the patient will be able to actually find? Do your office hours meet the needs of all patients, including those who may work shifts, rely on public transportation, or require childcare? Would it be acceptable—and more convenient—for the patient to return every 6 weeks rather than 4?

Keeping these factors in mind is how all physicians can move forward.

The Health Consequences of Racism

David R. Williams, PhD, MPH, is 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. He contributed to “Unequal Treatment” and has continued to study the effects of racism on health. He notes that while systemic and individual discrimination directly contributes to disparities in the provision of health care, individual discrimination also has a negative impact on an individual’s health.

His analysis of existing data has found that self-reported discrimination is related to defined psychological disorders, as well as to indicators of mental health symptoms and distress. Perhaps more surprising is the finding that self-reported discrimination is associated with preclinical indicators of disease, including increased allostatic load, inflammation, shorter telomere length, coronary artery calcification, dysregulation in cortisol, and greater oxidative stress.

Long-term stress had a negative impact on overall health, and the evidence shows that dealing with discrimination leads to stress. One study documented that changes in neural functioning associated with self‐reported experiences of discrimination mirror patterns observed for other psychosocial stressors.

There is also evidence that vicarious discrimination—discriminatory experiences that were not directly experienced by an individual but were faced by others in their network or with whom they identify—negatively impacts health, including for children.²

As a black woman, I face discrimination and microaggressions continuously. Like other black women, I have been assumed to be “the help,” sexualized and told to “use what I’ve got,” and had people ask to touch my hair.

My status as an accomplished professional doesn’t insulate me. I’ve been told I “look too young” to be a doctor, was told or had it implied that I wasn’t dressed properly when wearing a business suit, and fielded questions about “what’s going on” with my hair. These types of comments are commonly used to indirectly reference my race.

Although I have published more than 90 papers, conduct clinical trials, and lecture around the world, I am sometimes not taken seriously, including among other medical professionals. It took effort to be recognized by other physicians in the area as a leading dermatologist.

I am not alone among professionals. Research shows that black Yale graduates die earlier than their white counterparts. Among graduates of the class of 1970, the rate of early death at age 60 or younger was 3-times as high among black alumni compared to whites. Black males overall in the US tend to die younger than any other demographic group. Presumably upwardly mobile graduates of one of the country’s most prestigious universities would be protected from some of the many factors thought to contribute to premature death in black men. This phenomenon could reflect the long-term impacts of discrimination on these individuals. There is also speculation that the constant challenges and stress of trying to overcome discriminatory obstacles takes a health toll on these individuals.

Moving Forward

There is much work to be done, but already we are making some progress. Industry is addressing inequities in healthcare (Read  "Special Report: Dermatology Industry Responds to Inequities in Care"). One noteworthy program, the DREAM Initiative, is a partnership between Allergen Aesthetics and Skinbetter Science with The National Racial Equity Medical Residency Curriculum to assist students, faculty, and staff in dermatology and plastic surgery residency programs in identifying and addressing the risk of implicit bias in academic and clinical settings.

As part of the initiative, The Full Spectrum of Dermatology: A Diverse and Inclusive Atlas, is a dermatology atlas that will display images of the most commonly seen dermatology conditions in an array of skin tones. It was developed by co-editors Misty Eleryan, MD, MS, and Adam Friedman, MD.

The ASDS has an active DEI committee, chaired by Mona Gohara, MD and Omer Ibrahim, MD. I and members of the committee try to discuss every aspect of diversity, equity, inclusion, and accessibility and implement policy as well as give recommendations to the ASDS community about what we feel strongly should be best policies and practices for these areas. We are all currently mentoring younger residents and fellows and trying to teach our mentees about what the field of dermatology is truly like.

Finally, I encourage everyone to take Harvard‘s implicit bias test (implicit.harvard.edu) to see where they have bias blind spots are so that they can address them and be better students, residents, physicians, and people.

Racism is not just stress-inducing, it is exhausting for those of us who deal with it on a daily basis. The exacting stress on the human body produces increased levels of cortisol, which lead to many of the negative outcomes discussed above. Surely discrimination is a threat to public and individual health.

1. https://www.rwjf.org/en/blog/2017/10/discrimination-is-a-health-issue.html

2. Williams DR, Lawrence JA, Davis BA. Racism and Health: Evidence and Needed Research. Annu Rev Public Health. 2019 Apr 1;40:105-125.

3. Williams DR, Lawrence JA, Davis BA, Vu C. Understanding how discrimination can affect health. Health Serv Res. 2019 Dec;54 Suppl 2(Suppl 2):1374-1388.

4. https://www.wbur.org/news/2011/05/16/blake-yale-men-die-young