Racial differences in transfusion practices: Time to address structural racism

In this issue of TRANSFUSION, Prochaska and colleagues report a retrospective study of transfusion practices in hospitalized general medicine patients at a single academic center. Using electronic health record data, the authors analyzed hemoglobin transfusion triggers and total number of transfused units by reported race. Patients with sickle cell disease were excluded from the study. Participant demographics allowed for statistical comparison between three groups: Black/African American, White, and the collection of remaining ethnoracial categories (“Other”). The investigators found that overall, African American patients were less likely to be transfused than White patients (25% vs. 30%, p < 0.01), and this pattern held true for all nadir hemoglobin strata below 9 g/dl. Of note, the investigators did not adjust for potential confounders such as alloimmunization rates, which may have affected blood availability for individual patients. Still, the results shine a light on — and raise many more questions about — racial equity in transfusion practice, invoking our community for careful individual and organizational introspection.

Let us talk about racism today.

1 CEMENTED IN HISTORY: STRUCTURAL RACISM DEFINED

Structural racism involves more than individual prejudices and points of view. Instead, it refers to how society condones discriminatory practices and systems of oppression centered around laws and procedures/policies that codify preferential treatment based on race.² The conversation concerning the structural nature of racism is not new: two observations, 40 years apart, demonstrate the persistence of inequality.³ In a 1944 study of the role of race in American life, Gunnar Myrdal noted that “Area for area, class for class, Negroes cannot get the same advantages in the way of prevention and care of disease that whites can.”⁴ In 1985, the Report of the Secretary's Task Force on Black and Minority Health concluded that “Despite the unprecedented explosion of scientific knowledge and the phenomenal capacity of medicine to diagnose, treat and cure disease, Blacks, Hispanics, Native Americans, and those of Asian/Pacific Islander heritage have not benefited fully or equitably from the fruits of science or from systems responsible for translating and using health sciences technology.”⁵

More recently, Bailey et al. described the structural nature of racism, and how the system effectually works to control access to educational, economic, environmental, and community-based resources for Black and other underrepresented groups.⁶ These resources, referred to as the social determinants of health (SDOH), include “conditions in the environment where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.”⁷ The SDOH generally fall into five areas: economics, education, health care, environment, and community.⁷ Bailey and colleagues highlight instances of structural racism that still have an impact today.⁶ An example: in 1933 the Home Owners' Loan Corporation (HOLC) developed guidelines to determine mortgage-worthiness that included the creation of maps of over 200 U.S. cities that used racial composition as part of the assessment. HOLC staff literally drew red lines (hence the term “redlining”) around communities with Black populations, flagging them as hazardous investment areas and denying prospective homeowners HOLC loans. This left Black homebuyers vulnerable to predatory lending practices, reduced their access to home ownership, and deprived these communities of an asset that is central to intergenerational wealth transfer.⁶ This structural barrier prevented racialized people from actualizing the SDOH in the same way that others could. Addressing these structural barriers is essential to achieve equity. When individuals and communities have access to and delivery of quality education, safe and affordable housing, and opportunities for economic growth, they can attain their full potential for health and well-being.

Barriers in access to and delivery of health care exist too, and disparities among racial and ethnic groups in health care are well-documented. The Institute of Medicine's 2003 report “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care” concluded that bias, prejudice, and stereotyping contributed to widespread differences in health care by race and ethnicity.⁸ In 2018, the National Health care Quality and Disparities Report documented that Black, American Indian, Alaska Native, and Native Hawaiian and Pacific Islander patients continued to receive poorer care than White patients on 40% of the quality measures examined.⁹ The latter report noted little improvement in disparities since 2000.

Decades of research support the fact that racism is a public health threat that has deleterious effects on the health and welfare of African Americans, communities of color, and marginalized communities.³ What is different now? This country is at an inflection point brought on by the intersection of the Black Lives Matter movement and the COVID-19 pandemic. The Black Lives Matter movement is a Black-centered political and advocacy movement created in 2013 in response to the outcome of the trial of George Zimmerman, a white man tried for the murder of teen Trayvon Martin, in Sanford, FL.¹⁰ In 2020, this movement was reinvigorated by the murder of a Black man, George Floyd, by a white police officer in Minneapolis, MN. This incident, captured by witnesses on their cellphones and shared widely, led to what has been described as the largest movement in U.S. history.¹¹ At the same time, the country was experiencing the first surge of COVID-19. From the start of the COVID-19 pandemic, it was evident that Black/African American, Hispanic/Latino, American Indian, and Alaska Native persons in the US were experiencing higher rates of COVID-19-related hospitalization and death compared with the non-Hispanic White population.¹² Among other factors, racialized groups have higher levels of pre-existing comorbidities, predisposing them to COVID-19 complications. Racialized groups also endure higher rates of pandemic-related job loss, differences in health care insurance access, as well as chronic stress from lifelong and generational exposure to discrimination and hardship.^{13, 14}

This intersection of events and movements laid bare uncomfortable truths about our society. It shone a light. It is time to talk about racism and health care, to acknowledge its deep history and ongoing impacts, and to begin the institutional and individual work needed to dismantle this system and build a newer, equitable one.

2 THE FLEXNER REPORT AND HEALTH CARE PROVIDER RACIAL INCONGRUENCE

The 1910 Flexner Report,¹⁵ which has been cited as the “edifice that became the system of medical education” and made the US a world leader in medical education and research,¹⁶ left another legacy. Its recommendations de facto created a separate and unequal medical education system in the US. Flexner recommended that African American physicians be trained only as “sanitarians,” with a focus on hygiene and public health, and that they should only treat African American patients. Medical schools at the time were segregated, and the report recommended that five of the seven medical schools educating African American medical students be closed. The two remaining medical schools, Meharry Medical College (Nashville, TN) and Howard University Medical School (Washington, D.C.) were not to receive equal funding to their White medical school counterparts. These recommendations effectively crippled the growth potential of these institutions. Despite this, Meharry and Howard medical schools have produced multiple generations of capable, well-trained African American physicians that to this day are examples of African American excellence.

To this day, in the medical education system built on Flexner's recommendations, African American applicants do not have equitable access to medical education and experience lower rates of acceptance.¹⁷ In 2015, the overall medical student acceptance rate was 41.1% but for African American or Black applicants it was 34%.¹⁸ Today, only approximately 5% of practicing physicians are African American. The proportion of African American physicians has remained at or below this level for over 70 years, even as the African American population has grown to about 13% of the total US population.¹⁸ With patient-physician racial concordance associated with improved outcomes and increased patient satisfaction,^{19, 20} the separate and unequal medical education and training structure recommended by Flexner likely contributes to the health disparities that exist today. In response to this, the Beyond Flexner Alliance (BFA), an inter-professional organization of health care educators and providers, was created in 2015. The core goals of this organization include reducing health disparities, enhancing diversity, advancing community engagement, and using health care resources responsibly.²¹

3 STRUCTURAL RACISM AND HEALTH DISPARITIES

The US Department of Health and Human Services' Healthy People 2020 report describes a health disparity as “a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage.”²² The report notes that groups or people who have systematically experienced greater obstacles to health based on their racial or ethnic group, or “other characteristics historically linked to discrimination or exclusion,” are adversely affected by health disparities.²² When racialized groups experience differences in health outcomes, such as the COVID-19 complication rate described above, the definition of health disparity is met. In contrast, health equity, discussed in more detail below, is defined as the “attainment of the highest level of health for all people.” Due to the complexity of the factors leading to health disparities, achieving health equity is just as complex - inequities will not be solved by focusing solely on providing equal access to health care. Attaining health equity requires valuing individuals and communities as they exist, and providing what is needed to address avoidable and structural inequalities, historical and contemporary injustices, and eliminate health care disparities.²³

In this issue of TRANSFUSION, Prochaska et al. state that the observed variations in transfusion practice by race constitute a concerning health care disparity, since they represent “poor adherence to transfusion standards that are not supported by empiric data or guidelines.” Interestingly, their manuscript reports not only significantly fewer transfusions for African American patients below the hemoglobin threshold of 7 g/dl, but also higher transfusion rates in White patients above this restrictive transfusion guideline, raising the possibility of unnecessary transfusions in White patients. Thus, deviation in transfusion practice appears to occur in both Black and White patients in this dataset, albeit toward opposite ends of the spectrum. While health outcomes and other contributing factors are not accounted for in this study, these disparate practices warrant closer study and underscore a fundamental truth: health care equity efforts will not just benefit underrepresented groups. Health equity benefits everyone.

4 EXISTING RESEARCH AND UNANSWERED QUESTIONS

There is a dearth of transfusion medicine literature regarding health disparities for racialized people, as well as a lack of research on interventions to address racism in transfusion medicine and define its impact on transfusion outcomes and patient care. The study presented by Prochaska et al. is but one of the initial light rays that enters a home at daybreak, revealing an overpowering flood of questions arising from this work. Why do the described differences in practice exist? Which structural societal factors – cost, access, trust, information, language, cultural congruence – play a role? How do these factors affect the care of sickle cell disease patients, who were not included in this study? Is health care provider implicit bias a contributing factor? Do these findings reflect a lack of trust for the blood collector among racialized populations or a lack of available matched blood products for these patients due to limited donor diversity? Are alloimmunization rates a barrier? Would these disparities be evident in other geographic locations or centers, and how do they relate to local socioeconomic factors? Are there also disparities within the individual ethnoracial groups in the “Other” category that were less visible because of conglomeration and sample size?

Most importantly, we wonder how these inequities reflect on transfusion therapy and health outcomes. Why has it taken us so long to openly acknowledge these sorts of inequities, and how can we move toward equity in our field?

5 INCLUSIVE DATA COLLECTION, FUTURE RESEARCH, AND HEALTH EQUITY

While the work by Prochaska and colleagues is revealing, the study addresses only a limited group of defined racial categories and clinical scenarios, and it does not interrogate the intersection of race with other identity and socioeconomic factors. Intersectionality is an analytical framework for understanding how various aspects of a person's identity combine to create different modes of privilege and discrimination. It accounts for the many aspects of personhood and different aspects of identity that can compound advantage or disadvantage for each individual. Broader and more inclusive health data collection is imperative to accurately reveal, and subsequently address, health disparities for racialized communities. To achieve this, a data collection practice with a complete intersectional focus is essential. Gender, class, sexuality, race, ethnicity, religion, disability, physical appearance, and socioeconomic status are all intersecting and overlapping social identities that can be either empowering or oppressing in society.²⁴

Clear data from an intersectional perspective about the whole person being cared for is important to achieve the full potential of health equity. However, committing to robust data collection alone will not suffice. Without trust from racialized people, including trust that collected data will be used toward equity and improving the experience of equity-deserving groups, data will be difficult to obtain and may not be representative. Disaggregated race-based data that is collected in partnership with, and that meets the needs of, racialized communities is essential.²⁵

Community-based participatory research is a valuable tool to understand the experiences of racialized people receiving health care and inform subsequent intervention strategies. Community-based methodology was developed in response to the recognition of power differences between researchers and participating communities, acknowledging the harms experienced by these populations by traditional research through history. The community-based research approach emphasizes learning together and reciprocal transfer of knowledge and expertise, and a key aspect is sharing decision-making power throughout the entire research process.²⁶

Beyond conducting formal research studies or simply collecting data to support quality improvements, the next critical step is effectively applying new information to define interventions needed to achieve health equity. To fully embrace health equity, understanding the distinction between equality and equity is required. Health equality focuses on fairness and aims to ensure that people get the same things and are treated the same. However, equality only works if everyone starts from the same place and needs the same things. Health equity focuses on ensuring that people receive care in ways that are appropriate for their needs.^27-29

Health equity pursues the best health and health care for all people, paying special attention to those at greater risk of poor health or outcomes. It is defined as the absence of avoidable or remediable differences among groups of people, ensuring that all people have full access to opportunities that enable them to lead healthy lives.^{27, 28} As mentioned above, health equity benefits everyone. Equity-oriented health care (EOHC) requires allocation of sufficient resources to communities experiencing health and social inequities.³⁰ The findings from Prochaska et al. raise the need for a focus on EOHC for transfusion support in racialized groups.

6 DISMANTLING STRUCTURAL RACISM AND HEALTH DISPARITIES

Bailey and colleagues emphasized that confronting racism requires not only changing individually held beliefs, but also transforming and dismantling the policies, institutions, and beliefs upon which the racist structures are built.⁶ They suggest that medical and public health communities can contribute directly in four key areas. First, by committing to fully documenting the health impact of racism in mainstream medical journals, so this is viewed as valid research and can be provided substantial research funding. Second, by increasing the availability of data that includes race, ethnicity, and intersectional identities; and supporting efforts to develop, measure, and improve structural racism indicators. Third, by increasing the number of Black medical students and addressing the difficulty Black researchers face in receiving funding from the National Institutes of Health,^31-33 and ceasing the narrative that there is an inadequate pool of qualified Black applicants to recruit, hire, and promote in the medical field and in institutions of higher learning. Lastly, communities that perpetuate structural racism should (1) acknowledge the power and influence of social movements in challenging structural racism, and (2) admit their role in the history of opposing desegregation, not supporting increased access to care, barring Black physicians from practicing medicine, and championing scientific racism.⁶

The last aspect of dismantling structural racism involves individual personal work. Structural racism is painful to acknowledge, but a structure cannot continue to exist if the foundation is removed. We are at a time in history where we must openly engage around the issue of structural racism, its impact on an increasingly diverse population, and our responsibility as health care providers to first do no harm.

Health care providers can build up an armor that makes self-reflection difficult: “I am a good person” or “we are doing good things for patients/donors”; therefore, “I/we couldn't possibly be contributing to or be upholding/expressing racist beliefs.” This armor impedes change. Stereotypes are often not consciously endorsed, but these unconscious processes can lead to unintended biases (implicit bias) in decision-making. Implicit bias can contribute to health care disparities by shaping behavior and producing differences in health care according to race, ethnicity, gender, or other characteristics.³⁴ Everyone is susceptible to biases, including the health care community.

The self-reflection and personal work needed cannot be done solely through research and scholarly work. We must engage with people, volunteer, listen to what is important to diverse communities, have open discourse, be vulnerable, be honest with others, and especially be honest with ourselves. Everyone is called to do this work regardless of race, ethnicity, gender, or ability. We are all capable of change. In her article, “Racist Like Me — A Call to Self-Reflection and Action for White Physicians”³⁵ Dr. Deborah Cohan challenged herself to be introspective, to dismantle thoughts of race and bias, and to reflect on times when she might do more for a White patient than a patient of color. Ultimately, through her personal work, Dr. Cohan comes to understand the need to give herself grace. This reflective work is life-long. One thing is undeniable: implicit bias is a treatable condition.

So, let us pull back the curtain, let the light in, and get to work.

CONFLICT OF INTEREST

The authors have disclosed no conflicts of interest.