Inside Boston Hospitals, A Reckoning With Racism

As calls for racial justice continue on Boston streets, conversations have shifted to what’s next. That’s true inside hospitals as well, where the life-long effects of racism play out every day.

“You could almost take any chronic disease in America, diabetes, hyper-tension, and there will be higher rates and worse outcomes in Black Americans,” says Dr. Rose Olson, a resident physician at Brigham and Women’s Hospital. “That’s not due to biology or genetics, honestly it's due to racism and lack of access to care.”

Olson is among a group of residents at the Brigham and hospitals across the city who say it’s time to turn the vast outpouring of support for change — seen in hospital staff taking a collective knee to remember George Floyd, or heard in statements from hospital leadership — and turn that into steps that will eliminate racism and health disparities.

Health disparities are also playing out during the COVID-19 pandemic, with death rates for Black and Latinx adults seven to nine times higher than for whites.

Residents at the Brigham, Massachusetts General Hospital and Boston Medical Center are circulating petitions with specific requests. They include: a living wage for low income, often minority employees, providing equal care and equal access to care for patients covered by Medicaid, hiring more Black and underrepresented minority clinicians and changing the hospitals’ use of security.

These proposals are personal for many of the petition organizers. Dr. Yvonne Okaka, another Brigham and Women’s resident, works with a supervising physician on every shift. Okaka says she can only recall one Black attending doctor.

“And it was just once, he was covering for a Saturday,” Okaka says. “So that was once in my entire year.”

The Brigham petition asks that the hospital step up recruitment so that 5% of faculty and staff are Black by 2022. Okaka says she knows this won’t be easy. Boston, with its history of racial strife, is still not seen as an appealing place to work for some minorities. But Okaka says boosting their presence would help minority patients be more open with their providers and get better care.

Another request could be more difficult: increasing the amount of free care and the percentage of Medicaid patients the hospital sees. An analysis from the state’s Center for Health Information and Analysis shows 12% of the Brigham’s patient charges were to Medicaid in 2018, and 13% at Mass General. The statewide average was 18%. A shift from private insurance to more Medicaid payments could cost a hospital tens of millions of dollars because private insurers pay more, often twice as much or more, than does Medicaid for the same appointment, test or procedure.

This too, is personal for Okaka. When she decided to go to medical school, Okaka had to submit some medical test results, but she was uninsured. Okaka says she found a free clinic that drew blood and ran the results, otherwise, she wouldn’t have been able to complete the applications.

“I won’t say this is easy,” Okaka says of these appeals. “I know it’s really hard, but it’s imperative if we’re going to see this country, this hospital, this institution move forward, move in the right direction.”

The discussions about what hospitals can do to help fix racial injustices come as revenues plummet. The Mass General Brigham hospital network, formerly known as Partners HealthCare, says revenue could be down as much as $2 billion this year, although steps to cut spending will help.

“As we look at the financial situation that health care organizations are facing, and we’re no different, what’s realistic?” says Tim Ewing is vice president of employee diversity, inclusion and experience at the Brigham. “There are so many factors that come into play. The discussions, the reality, looking at our financial picture, that becomes the big deciding factor for us.”

And, says Ewing, changes at the Brigham and Mass General could affect all 12 hospitals in the network, which makes balancing the effects more complicated.

There are calls at these hospitals, as in the general public, to rethink the way health care institutions interact with or use police and in-house security officers. Dr. Joe Betancourt, vice president and chief equity and inclusion officer at Mass General, says changes are already underway.

“I get a report of any incident related to racism, sexism or any of the ‘isms,’ ” he says. “We track that and then we’ve been building a way to reconcile those concerns once they get identified.”

The MGH petition goes further. It suggests eliminating the budget for hospital security and using that money for more social work and mental health services. And there’s a call to remove the names and images at Mass General of anyone linked to racism or white supremacy. Betancourt says these and many other ideas are coming to the fore during hospital-wide and smaller group discussions. He says Mass General is working on a plan with immediate and longer term steps.

“We want to make some commitments within the next couple of weeks,” he says. “That’s the window of opportunity we have and that’s the urgency that this time calls and asks of us.”

Ewing says the Brigham is considering the needs of and requests from a number of different groups within the hospital as it works to answer this question.

“How do we make a concerted effort so this is not just window dressing, it actually is making deep, long systemic change that we can see, touch and feel?” he says.

Dr. Valerie Stone, the vice chair for diversity, equity and inclusion at Brigham and Women’s, is advising hospital residents on strategies to racial injustice. Stone says the impact of racism on Black hospital staff and patients is still not well understood.

“Our lives, despite relative privilege, have often been challenged by an appalling juxtaposition of either complete invisibility or, when seen, being seen as dangerous, a likely criminal, or at best simply unimportant,” Stone writes in an essay published by the Annals of Internal Medicine. "We are pulled over by police for no reason; we fear for our lives.”

During town halls, small group dialogues and hallway heart-to-hearts, hospitals are exposing pain not all are used to treating. That’s also true at Boston Medical Center, which has a long history of trying to curb health disparities.

“I’ve heard conversations in the last three weeks, that I’ve not heard before,” said Dr. Thea James, vice president of mission at BMC. “I’ve heard levels of vulnerability that I’ve not heard before. It’s an opportunity to dig a little deeper and strip the floor and not be afraid.”

But which steps will be most effective, after these difficult conversations, is an open question. Dr. Camara Jones, a family physician, epidemiologist and past president of American Public Health Association, says there’s lots of research about how to measure health inequities, but much less about which interventions work.

“Even though we haven’t tried a lot of these things,” she says, “I am encouraged that they are very much on the right track. Because in its essence, racism is not a cloud. It is a system with identifiable and addressable mechanisms, which are in our decision-making processes.”

Jones says better decision-making starts with having more Blacks and other underrepresented minorities on staff at hospitals, it means more data to help explain why Black patients are less likely to be referred for specialized care. And It means writing policies to correct differences in care.