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Educational Affairs
Let's talk about it: Health Equity, Racism, and Cultural Humility

by Klodiana Myftari, PharmD, BCACP Assistant Professor of Pharmacy Practice; Midwestern University Chicago College of Pharmacy; Sally Arif, PharmD, BCPS, BCCP Associate Professor of Pharmacy Practice; Midwestern Univer

The year 2020 has really highlighted our limitations as a society, exacerbated our fears and insecurities, and shined a spotlight on inequity. Over the last several months, many of us have paused and asked, “How did we get here?” For many, including some of our patients, the fear, insecurity, and disparities have been present for generations. The current year has simply made things more visible and brought to light the work that needs to be done to combat racism and its impact on healthcare.

Health equity, defined as the opportunity for everyone to attain their highest level of health, is a concept that is taught in every healthcare professional school.¹ However, it is not always understood and is difficult to implement. Health equity cannot exist without racial and social justice. Unfortunately, disparities fundamentally fueled by race/ethnicity, gender, sexual orientation/gender identity, and disability status, persist across our nation. Racism and long-term discrimination have precipitated social and economic issues that are pillars of health inequity. “Racism” is a system of structuring opportunity and assigning value based on the social interpretation of how one looks (which is what we call “race”) that unfairly disadvantages some individuals and communities, unfairly advantages other individuals and communities, and saps the strength of the whole society through the waste of human resources.² This definition speaks to a system designed by individual social interpretation of assigned value. The question we should all ask ourselves is, “What is my individual interpretation of assigned value based on how one looks?” This self-reflection moves the conversation from the system to the individual. We must challenge ourselves to think beyond our role as a healthcare provider to our moral responsibility as individuals when it comes to serving those who are marginalized in our society. This challenge starts by gaining self-awareness and reflecting on our individual journey towards cultural humility.

Cultural Humility, Self-Awareness, and Biases

Cultural humility is part of lifelong learning that requires consistent self-reflection. It can be defined as the “ability to maintain an interpersonal stance that is other-oriented (or open to the other) in relation to aspects of cultural identity that are most important to the [person].”³ The journey towards cultural humility starts with self-awareness, which is a key component of cultural awareness. Understanding our own values, beliefs, norms, and customs also comes with uncovering what stereotypes and biases we may unintentionally carry.

Healthcare professionals have been found to have the same degree of implicit bias - otherwise known as unconscious bias- as the general population.⁴Unlike explicit biases, of which one is aware, implicit biases exist in the subconscious, are learned by associations over a lifetime, and can unintentionally contribute to unequal care of disadvantaged populations. They can lead to quick judgments about others and are often rooted in unsupported assumptions about race, ethnicity, socio-economic status, sexual orientation, or gender. The good news is that many of our implicit biases do not align with our outward explicit values or feelings; however, they can still unconsciously influence the degree of active listening and empathy we may provide to our patients. Unconscious biases can unintentionally lead to the under-treatment of pain, cardiovascular disease, asthma, and mental health, especially for racial minorities.

Cross-Cultural Communication

Engaging with “others” who are different from you is a de-biasing strategy that can assist with reducing negative stereotypes that can impact interactions with patients.⁵ Cultural identity is central to all patient interactions. However, culture goes beyond the obvious characteristics of race, ethnicity, gender expression, and language to include deeper parts of our identities such as belief systems, world views, and attitudes. Understanding a patient’s culture, which dictates human behavior and action, allows us to build a better rapport and uncover health beliefs that can impact adherence with health plans. Enhancing our cross-cultural communication skills requires practice and time. Models such as SOLER and LEARN provide strategies to cultivate genuine, culturally sensitive relationships with our patients.^6,7 (See Table 1).

Cross-cultural communication strengthens our cultural awareness. It is a catalyst on one’s journey toward cultural humility. As individuals and healthcare providers, we move from cultural awareness to cultural knowledge when we are able to analyze the similarities and differences between our culture and that of others.⁸ Conversations with our patients and fellow healthcare professionals around values and beliefs that affect one’s health moves us towards cultural sensitivity. Finally, cultural competency is when we can adjust how we think and behave to support our diverse patients.⁸

Our challenge in the path towards cultural humility, health equity, and anti-racism will be to continue the conversations without these words losing their true meaning. Keep talking and asking uncomfortable questions. Let us continue the journey toward cultural humility together. It is our responsibility as healthcare professionals to recognize and challenge power imbalances and demand institutional accountability for all our patients.⁹

References

American Public Health Association. Health Equity. Available at https://www.apha.org/topics-and-issues/health-equity. Accessed October 6, 2020.
Jones CP. Toward the science of practice of antiracism: launching a national campaign against Racism. Ethn Dis. 2018;28(suppl 1):231-234.
Hook JN, Davis DE, Owen J, Worthington EL, Utsey SO. Cultural humility: measuring openness to culturally diverse clients. J Couns Psychol. 2013;60(3):353-366. [published correction appears in J Couns Psychol. 2015 Jan;62(1):iii-v].
FitzGerald C, Hurst S. Implicit bias in healthcare professionals: a systematic review. BMC Med Ethics. 2017;18(1):19.
Devine PG, Forscher PS, Austin AJ, Cox WT. Long-term reduction in implicit race bias: A prejudice habit-breaking intervention. J Exp Soc Psychol. 2012;48(6):1267-1278.
Berlin EA, Fowkes WC. A teaching framework for cross-cultural health care. W J Med. 1983, 139:934-938.
Egan G. The skilled helper: a problem management and opportunity approach to helping. Pacific Grove, CA: CambridgeBrooks/Cole; 2002.
The Winters Group, Inc. Cultural Competence ModelTM. Available at: http://www.theinclusionsolution.me/what-is-inclusion-part-2-inclusion-starts-with-i/. Accessed October 6, 2020.
Tervalon M, Murray-García J. Cultural humility versus cultural competence: a critical distinction in defining physician training outcomes in multicultural education. J Health Care Poor Underserved. 1998;9(2):117-125.