Having seen the raw inequity the pandemic exposed in the healthcare system, one would think it has become harder to deny or rationalize the lack of diversity in caregivers and higher adverse outcomes in marginalized patient populations. But one would be wrong.
Organized conservative groups are targeting healthcare in an attempt to gut diversity, equity, and inclusion (DEI) programs. Of course, the effects of these programs span across healthcare, but infection control has drawn a key role in this fight — particularly because of concerns about higher rates of healthcare-associated infections (HAIs) and substandard antibiotic delivery in patients of color and those vulnerable because of their socioeconomic status and social determinants of health.
There is an accumulating body of research documenting inequities in HAIs, antibiotic care, and a shortage of Black primary care physicians — providers who are directly associated with improved survival-related outcomes for Black patients.1-3
For example, a scoping review looking at antibiotic use found that “Black children were 28% less likely to receive antibiotics when they were indicated for acute respiratory tract infections. Among hospitalized adults, … Black patients were less likely to receive first-line treatment for skin and soft tissue infections compared to white patients.”2
The Association for Professionals in Infection Control and Epidemiology (APIC) has created a health equity committee, which is working on defining the role of infection preventionists and is planning to ultimately issue recommendations to address inequities. Tania Bubb, PhD, RN, CIC, FAPIC, 2024 president of APIC, has made addressing healthcare inequity a priority of her term. (See Hospital Infection Control & Prevention, April 2024).
Jasmine Marcelin, MD, FACP, FIDSA, vice chair of equity and professor of infectious diseases at the University of Nebraska Medical Center, recently wrote a sweeping commentary on this issue.
“Developing an organizational health equity committee is an important first step in demonstrating that this is a priority,” she tells HIC. “Infection preventionists and healthcare epidemiologists can play a role by requesting and collecting data disaggregated by race and analyzing trends in their hospital reports to identify any signals related to health inequities. Once they identify these, they should investigate potential causes and consider how patient social determinants of health interact with structural racism to influence the risk for developing infections.”
Marcelin and colleagues define the problem as follows: “Health inequities occur when unfair processes in the distribution of resources affecting health disproportionately prevent the attainment of that highest level of health in specific populations. Health inequities are pervasive and lead to differential patient outcomes for a variety of disease states, ranging from chronic diseases, like type 2 diabetes mellitus and hypertension, to infections like COVID-19. Infection risk in healthcare and quality of antibiotic use vary by patient population.”4
Supportive research includes disparities related to multidrug resistance, HAIs, Candidemia, and Clostridioides difficile.5-7 For example, researchers report that minority patients “with C. diff infections [CDIs] had prolonged hospitalizations and increased intensive care unit admissions. Chronic kidney disease was shown to partially mediate the relationship between race or ethnicity and severe CDI. Our findings suggest potential areas for equitable interventions.”8
CDC, CMS, Joint Commission Stepping Up
The Centers for Disease Control and Prevention (CDC) has taken a high-profile role on this issue, forming an Office of Health Equity (OHE) that is raising awareness and encouraging action.
“The future health of the nation will be determined to a large extent by how effectively we work with communities to eliminate health disparities among those populations experiencing a disproportionate burden of disease, disability, and death,” the CDC OHE states.9 “Persistent health disparities in our country are unacceptable and correctable. CDC advances health equity and women’s health issues across the nation through CDC’s science and programs. OHE also increases CDC’s capacity to leverage its diverse workforce and engage stakeholders.”
In addition, last year, the Joint Commission created a voluntary advanced certification for healthcare equity to help organizations close the gaps in access and quality among patient groups where disparities are frequent. The Joint Commission cited a few stats that give a snapshot of the problem, including that the maternal mortality rate for Black women is four times higher than that for non-Hispanic white women and that diabetes rates are more than 30% higher among Native Americans and Latinos than among whites.10
The Joint Commission also made healthcare equity a National Patient Safety Goal, with NPSG.16.01.01 emphasizing that “improving healthcare equity is a quality and patient safety priority. For example, healthcare disparities in the patient population are identified and a written plan describes ways to improve healthcare equity.”11
The Joint Commission is a deemed authority for the Centers for Medicare and Medicaid Services (CMS), which has launched a 10-year plan to address healthcare inequities. This includes assistance in helping organizations set up programs and access the necessary data.
“The Health Equity Technical Assistance Program helps healthcare organizations ready themselves to systematically take action to address health and healthcare disparities,” the CMS reports.12 “[This includes] personalized coaching and resources to help embed health equity into a strategic plan; help with data collection and analysis; and help developing a language access plan and ensuring effective communication with individuals, families, and caregivers.”
The Gathering Storm
That is an immense weight of evidence with the endorsement of high-profile organizations, but it appears the attacks against DEI programs in healthcare are going to accelerate.
For example, as noted by the Joint Commission, pregnant Black women have a four-fold higher risk of maternal mortality than whites. In San Francisco, the Abundant Birth Project pays approximately $1,000 to qualified pregnant Black and Pacific Islander women to ostensibly ensure they can afford things such as transportation for medical visits for prenatal care. The program faces an uncertain future after being sued by a group called Californians for Equal Rights Foundation, which claims basing the stipends on the race of the expectant mother is unconstitutional.13
The most recent example is the introduction of a bill by Republican Congressman Greg Murphy, MD, (U.S. Rep-NC), that would effectively ban DEI programs in medical school. The bill “would cut off federal funding to medical schools that force students or faculty to adopt specific beliefs, discriminate based on race or ethnicity, or have diversity, equity, and inclusion offices or any functional equivalent. The bill would also require accreditation agencies to check that their standards do not push these practices, while still allowing instruction about health issues tied to race or collecting data for research.”14
Of course, such federal legislation may never pass given the current political uncertainty, but many state legislatures are moving on anti-DEI laws. This issue is somewhat akin to the reverse discrimination claims of the past, which, put bluntly, argue that you cannot correct historical inequities by penalizing those who advanced through past advantages like what the Southern Poverty Law Center calls “white privilege.”15 To cite but one example, Black soldiers, after World War II, did not benefit from all of the provisions in the G.I. Bill, particularly the guaranteed low-interest mortgages for soldiers. “Black veterans were not able to take advantage of this benefit because banks would not make loans for mortgages in Black neighborhoods,” the Smithsonian reports.16 “Additionally, they faced rampant racism if they attempted to buy into suburban neighborhoods, which at the time were overwhelmingly white.”
Along these lines, a national organization called Do No Harm is targeting DEI programs in healthcare with lawsuits and complaints to the U.S. Office of Civil Rights. “Many U.S. medical schools offer scholarships and programs that illegally discriminate based on sex, gender identity, race/ethnicity, color, or nationality,” Do No Harm states on its website.17 “We have filed more than 100 civil rights to challenge them.”
Jenner & Block LLC, a law firm looking at this issue, cites Article III of the Constitution, which establishes the judicial branch, as the best defense for healthcare organizations. Essentially, this article requires that those aggrieved must establish actual harm against them that would be remedied by a verdict in their favor.
“Review eligibility requirements and public-facing statements for DEI programs,” the law firm recommends.18 “Across claims, Article III standing continues to be the biggest obstacle for Do No Harm’s anti-DEI efforts, partly due to the difficulty in alleging a concrete injury for anonymous plaintiffs who have yet to apply — and be rejected from — diversity programs in healthcare.”
The Dam Breaks
The ruling that broke the dam on this issue was the June 29, 2023, U.S. Supreme Court decision to eliminate race as a factor in college and medical school admissions.
A dissenting opinion by Justice Sonia Sotomayor warned that, “Experience teaches that the consequences of today’s decision will be destructive. Superficial colorblindness in a society that systematically segregates opportunity will cause a sharp decline in the rates at which underrepresented minority students enroll in our nation’s dissenting colleges and universities, turning the clock back and undoing the slow yet significant progress already achieved.”19
The American Nurses Association (ANA) concurred, saying, “For equity to exist, equality must first exist. This ruling ignores the reality of inequality and discriminatory practices and policies. Inevitably this decision will impact the admissions process for schools of nursing, a necessary pipeline for diversity within the profession to provide culturally competent and equitable healthcare.”20
Rep. Murphy’s federal proposal to ban DEI programs in medical schools drew a similar reaction from Marcelin.
“The data is clear that diversity drives excellence, and that delivering healthcare through a lens of equity leads to better outcomes not only for people from minoritized backgrounds, but better outcomes for all people,” she tells Hospital Infection Control & Prevention. “These bills and attacks on the values of justice, equity, diversity, and inclusion in healthcare are part of a larger, intentional strategy to solidify structural racism in healthcare and education by rolling back the progress that has been made in this country toward achieving equality and justice over the last 50 to 100 years.”
For example, the aforementioned study of Black primary care providers (PCPs) could have scarcely drawn a clearer and more direct conclusion: “Greater Black PCP representation levels were associated with longer life expectancy and were inversely associated with all-cause mortality rates for Black individuals,” the authors reported.
“They hope to [reduce] the number of physicians from minoritized backgrounds, ban discussions about equitable healthcare, and pretend that health disparities do not exist,” Marcelin says. “Those of us who are advocates for equity in healthcare will continue our efforts to galvanize the general public. We will continue to train doctors from minoritized and historically excluded backgrounds and continue to ensure that patients experience care through a lens of equity. This work never ends, and we are in it for the long haul.”
Multiple obstacles have been in the way of achieving equity on various fronts, including the longstanding need for racial and minority specific surveillance data for HAIs. The CDC’s National Healthcare Safety Network is expected to change this in fall 2024 so race and ethnicity would not merely be an optional data point.
There still seems to be no clear-cut surveillance data being collected nationally that would identify bias or inequity on antibiotic delivery and stewardship. It raises the time-honored adage in infection prevention and control: To control something, you must first be able to measure it.
“Further, we must use the right tools to measure problems before addressing them,” Marcelin says. “Collecting race data may be less useful if this is done inconsistently or inappropriately — for example, ‘assuming’ a person’s race. This must be used responsibly, with the understanding that race is a sociopolitical construct, not biological. Understanding the role that structural racism plays in health inequities is an important tool to address them.”
This idea of a “sociopolitical construct” rather than a biological classification can be an elusive distinction, but the principal points are that there is more genetic variation within racial groups than between them: All humans are genetically similar to a remarkable degree, sharing an estimated 99.6% to 99.9% of their genetic code.21,22
However, the permutations of skin color have been used to justify all sorts of despicable conduct toward one race or another, and led to the medical dogma that made racism part of the healthcare system. In this regard, historically, racism in medicine was manifested primarily as explicit or implicit bias by white clinicians toward Black patients.
“Unfortunately, the legacy of this false belief in fundamental and innate biological differences between Blacks and whites is still present in medical practice, leading to health disparities such as the undertreatment of pain in
Black patients,” the researchers emphasized.23
REFERENCES
- Gettler EB, Kalu IC, Okeke NL, et al. Disparities in central line-associated bloodstream infection and catheter-associated urinary tract infection rates: An exploratory analysis. Infect Control Hosp Epidemiol 2023;44:1857-1860.
- Kim C, Kabbani S, Dube WC, et al. Equity and antibiotic prescribing in the United States: A systematic scoping review. Open Forum Infect Dis 2023;10:ofad440.
- Snyder JE, Upton RD, Hassett TC, et al. Black representation in the primary care physician workforce and its association with population life expectancy and mortality rates in the US. JAMA Netw Open 2023;6:e236687.
- Marcelin JR, Hicks LA, Evans CD, et al. Advancing health equity through action in antimicrobial stewardship and healthcare epidemiology. Infect Control Hosp Epidemiol 2024;45:412-419.
- Brown DR, Henderson HI, Ruegsegger L, et al. Socioeconomic disparities in the prevalence of multidrug resistance in Enterobacterales. Infect Control Hosp Epidemiol 2023;44:2068-2070.
- McGrath CL, Bettinger B, Stimpson M, et al. Identifying and mitigating disparities in central line-associated bloodstream infections in minoritized racial, ethnic, and language groups. JAMA Pediatr 2023;177:700-709.
- Grant VC, Zhou AY, Tan KK, Abdule-Mutakabbir JC. Racial disparities among candidemic patients at a Southern California teaching hospital. Infect Control Hosp Epidemiol 2023;44:1866-1869.
- Lee JM, Zhou AY, Ortiz-Gratacos NM, et al. Examining the impact of racial disparities on Clostridioides difficile infection outcomes at a Southern California academic teaching hospital. Infect Control Hosp Epidemiol 2023;44:1-5.
- Centers for Disease Control and Prevention. About CDC’s Office of Health Equity (OHE). Last reviewed Aug. 4, 2023. https://www.cdc.gov/healthequity/about/index.html
- The Joint Commission. Advancing health equity, together. https://www.jointcommission.org/our-priorities/health-care-equity/
- The Joint Commission. National Patient Safety Goals. January 2024. https://www.jointcommission.org/standards/national-patient-safety-goals/-/media/165e86f799754481bdd1d554e92b8581.ashx
- Centers for Medicare and Medicaid Services. CMS Framework for Health Equity 2022-2032. https://www.cms.gov/files/document/cms-framework-health-equity-2022.pdf
- Cohen R. Backlash to affirmative action hits pioneering maternal health program for Black women. The 19th. Published Nov. 21, 2023. https://19thnews.org/2023/11/affirmative-action-backlash-maternal-health-program-black-women/
- U.S. Congressman Gregory F. Murphy, M.D. Murphy introduces bill to ban DEI in medicine. Published March 19, 2024. https://murphy.house.gov/media/press-releases/murphy-introduces-bill-ban-dei-medicine
- Collins C. What is white privilege, really? Recognizing white privilege begins with truly understanding the term itself. Southern Poverty Law Center. https://www.learningforjustice.org/magazine/fall-2018/what-is-white-privilege-really
- Smithsonian American Art Museum. After the war: Blacks and the G.I. Bill. https://americanexperience.si.edu/wp-content/uploads/2015/02/After-the-War-Blacks-and-the-GI-Bill.pdf
- Do No Harm. https://donoharmmedicine.org/
- Jenner & Block LLC. Client Alert: Healthcare industry emerges as the new front for anti-DEI attacks. Published March 12, 2024. https://www.jdsupra.com/legalnews/client-alert-healthcare-industry-1520568/
- Supreme Court of the United States. Students for Fair Admissions, Inc. v. President and Fellows of Harvard College. Decided June 29, 2023. https://www.supremecourt.gov/opinions/22pdf/20-1199_hgdj.pdf
- American Nurses Association. ANA responds to SCOTUS ruling against affirmative action programs. Published June 30, 2023. https://www.nursingworld.org/news/news-releases/2023/ana-responds-to-scotus-ruling-against-affirmative-action-programs/
- Rosenberg NA, Pritchard JK, Weber JL, et al. Genetic structure of human populations. Science 2002;298:2381-2385.
- Tishkoff S, Kidd KK. Implications of biogeography of human populations for ‘race’ and medicine. Nat Genet 2004;36(Suppl 11):S21-S27.
- Togioka BM, Duvivier D, Young E. Diversity and Discrimination in Healthcare. StatPearls [Internet]. StatPearls Publishing; 2024 Jan-.
Having seen the raw inequity the pandemic exposed in the healthcare system, one would think it has become harder to deny or rationalize the lack of diversity in caregivers and higher adverse outcomes in marginalized patient populations. But one would be wrong.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content. TESTING
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content