MADDIE SOFIA, HOST:
You're listening to SHORT WAVE from NPR. Rachel Hardeman has always known that racism and health care go hand in hand.
RACHEL HARDEMAN: Because as a kid and just growing up as a Black person in our society, it was very clear to me just from, you know, watching my family and other folks. It was very clear that not everyone has the same opportunities.
SOFIA: From things like access to basic health care to being able to see a doctor who understands your particular life experience. So Rachel went on to dedicate her career to understanding the role race plays in all of this as a health equity researcher and professor at the University of Minnesota.
HARDEMAN: With a focus on racism and understanding the ways that racism gets under the skin and impacts the health outcomes for Black moms and babies.
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SOFIA: In the U.S., Black infants die at over twice the rate of white infants. And there's an even greater racial disparity when you look at the mortality rates of the person giving birth. That's something Rachel wants to change by first understanding why.
HARDEMAN: We know that chronic or sort of toxic stress across the life course contributes to adverse birth outcomes for Black moms and babies. So because of racism and other social disadvantages that are playing out in people's lives, they come into pregnancy less healthy.
SOFIA: Rachel and a team of colleagues wanted to find out even more about the reasons behind the disproportionately high mortality rates for Black birthing people and their babies. What about the race of the doctor at the time of birth? Could that make a difference? So they looked into it, and what they found was stark.
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SOFIA: So today on the show, Black infant and maternal mortality - new evidence of the critical role a doctor's race could play in the survival of Black newborns. I'm Maddie Sofia. And this is SHORT WAVE from NPR.
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SOFIA: So, Rachel, let's jump into this latest research. What was the big question your team was kind of trying to answer? What were you looking at?
HARDEMAN: So we were interested in really understanding patient-physician racial concordance, meaning, does it matter if a patient has a physician caring for them that shares the same racial identity and racial background? The other piece is that, you know, with respect to infant mortality, for as long as we have collected data on infant mortality, there has been a racial gap. And so even when as a country, our infant mortality rates have improved, the gap has remained the same between Black and white babies or gotten worse.
The other piece that I think is really critical or interesting for this study is that it gave us an opportunity to understand if patient-physician racial concordance matters when communication is part of the scenario. So, of course, infants can't talk. And, you know, so often, we - you know, we've looked at the concordance question with respect to communication issues or lack of communication between a patient and a provider. And so this study really presented an opportunity to dig into all of those things.
SOFIA: Right, right. And so how did your team go about this, Rachel? Like, what data did you pull to look at?
HARDEMAN: So we used data from the state of Florida's Agency for Health Care Administration. And these data have been used extensively in public health and economics research to look at patients admitted to Florida hospitals between 1992 and 2015. So we were able to look at 1.8 million births between that time period and were also able to access detailed information about both the mother and the newborn, including their race, comorbidities, outcomes and the hospital that they were treated at. We had less information, actually, about the race of the physician because that's not a variable that's actually collected or coded very accurately or often. And so we had to get a little bit creative with that piece of it. And we actually employed sort of an army of graduate research assistants. One of my colleagues was able to hire 10, 15 students to help us pull all of the physician names and photos.
So in addition to what data we did have around physician race, we also had folks who were looking at pictures of physicians and identifying race in that way, as well, which I think is an important and unique, actually, part of this study because, you know, so much of how we as humans sort of categorize and group people and think about sort of racial identity is based on what we see in front of us. And so we were able to add that element to our dataset, as well.
SOFIA: So Rachel's team looked at the 1.8 million hospital birth records - how each baby did, the baby's race and the race of the doctor in charge of the newborn's care. And what they found was striking.
HARDEMAN: When a Black newborn was cared for by a Black physician. They were less likely to experience death in the hospital setting.
SOFIA: To put some numbers on it, when cared for by white physicians, Black newborns in this study were approximately three times more likely to die in the hospital than white newborns. But when Black physicians cared for Black newborns, that excess mortality rate dropped by about 50 percent.
HARDEMAN: We also found that the effects appear to sort of manifest themselves more strongly the more complex the case is.
SOFIA: Meaning the effect is even more prevalent in complicated or difficult birthing situations. But when the team looked at the health outcome of the birthing person, racial concordance didn't seem to make a difference.
HARDEMAN: You know, that's a really interesting piece that I - and was an unexpected finding for me based on the body of research that I do. We didn't see that there was a significant improvement in maternal mortality when the birthing mother shared the race with their physician.
SOFIA: Yeah. OK, OK, Rachel. So your study found this relationship between the race of the doctor and the baby's survival but didn't necessarily go into all the reasons behind it, right?
SOFIA: What's your sense of some of the reasons that this might be true - that Black babies die more often under the care of white doctors?
HARDEMAN: So this is kind of the hard or the complex piece of our study, you know, 'cause first of all, you know, it's important for me to say, you know, this study does not dig into the mechanisms behind what's happening here. But I would say that my scholarship sort of more broadly does. You know, I think the first thing to understand is that embedded within racial inequities in birth outcomes are the sort of ongoing effects of institutional or structural racism and the history of what that means in our country and the history of enslavement of Black people and how it's been embedded in all of our institutions, including our health care institutions.
So, you know, I think we often rely on, you know, the Tuskegee Syphilis Experiment as an example of the harm that's been done to Black people within our health care system. But that's one of many, many examples. You know, when we talk about maternal and infant health, I think it's important to understand the way that Black people were treated during slavery, where they were experimented on by the father of modern gynecology, James Marion Sims. And what that's meant sort of across, you know, decades, really - and that's not to say that, you know, physicians are going into practice and care for people and being explicitly racist. That's not at all the point we're trying to make. I think what's important to understand is that history and those harms are so deeply embedded in...
HARDEMAN: ...Our health care delivery systems. And we have to - we haven't reckoned with it, and we haven't learned that history. We haven't taught it to our future physicians, our current physicians. And so, you know, whether we want it to be or not, it's brought into the room, and it's brought into that space.
SOFIA: When it comes to looking forward and addressing inequities for Black patients, there simply are not enough Black doctors to see all Black patients. Black doctors make up just 5% of the physician workforce, while Black people make up 13% of the U.S. population. But Rachel says Black patients seeing only Black doctors - is it really the goal? But she does want people to have the choice.
HARDEMAN: So if I want to see a Black doctor, I should be able to go online and find one without much of a struggle, right? But I also, you know, recognize - I think we also recognize that it's not sort of realistic to rely sort of only on diversifying the physician workforce. We have to do a better job of ensuring that our current physician workforce, you know, has the tools to care for every patient that walks through their door. And so some of that means improving our training.
So for example, I'm working with a group called Diversity Science to develop a antiracism training for perinatal care providers in the state of California that will walk them through sort of the history of racism in our country and how it shows up in contemporary health outcomes and health inequities and also how it shows up in how we deliver health care to families and birthing people. And, you know, I think that's an important piece of the puzzle, but training actually isn't going to be fully effective if we're not thinking about institutional change.
You know, I - myself and two of my colleagues - we wrote a piece that was published in The New England Journal of Medicine just after the murder of George Floyd in my community. George Floyd was murdered just six blocks from where I grew up. And it was a call to action to really think about how to make health equity and achieving health equity an institutional value and something that is part of the day to day. Rather than sort of trying to retrofit it on the back end, I think we have to be thinking innovatively right now about how to lead with that. You know, just like we mandate that, you know, physicians learn anatomy or how to diagnose cancer...
HARDEMAN: ...You know, the structural racism and health inequities have to be part of that, as well.
SOFIA: Yeah. So, Rachel, I've looked through your very extensive research background. I mean, you've been researching structural racism in health care for a long time. And I'm wondering, you know, like, on a personal level if it just feels different, you know, like, talking about it right now at a time when perhaps a lot of America is finally giving more attention to social determinants of health. Like, does this feel different?
HARDEMAN: It feels different. It absolutely feels different. I think the sort of confluence of the murder of George Floyd and the COVID-19 pandemic and particularly the lens on the ways that COVID-19 is disproportionately impacting Black communities and other communities of color has led to conversations that I didn't think we would be having for 10 more years, 15 more years. And so I think it's been a really exciting time to sort of be a thought leader in this space but also a frustrating time because, you know, part of me is like, welcome to the party.
SOFIA: Right, right.
HARDEMAN: Like, now let's go. But, you know, it's - part of it is waiting for folks to catch up. But also, I think we've seen innovation happen with respect to COVID-19 and how we do care, which to me says, OK, if we can do that for this pandemic, for COVID-19 as a pandemic, we can do the same for racism as a pandemic. And so I think there's a lot of value in sort of looking at these pandemics side by side or in parallel but also in the ways that they sort of intersect to impact a lot of people in our society right now.
SOFIA: OK, Rachel. Well, I really appreciate your time and your work. Thank you so much for coming on the show and talking with us.
HARDEMAN: Thank you so much for having me.
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SOFIA: This episode was produced by Brit Hanson, fact-checked by Ariela Zebede and edited by Viet Le. Thanks for listening to SHORT WAVE from NPR.
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