Equity in Health Care

By Jill Tyrer |Nov. 10, 2022

African Americans, Hispanic Americans and other people of color in the United States are generally less likely to get timely, effective health care and more likely to have poorer health outcomes than white Americans. That inequity has been shown in numerous studies — and it’s no less true for those living with arthritis.

That’s why the Arthritis Foundation is doubling down on efforts not only to pave the way for more people from neglected communities to receive care. We’re also focused on increasing diversity, equity and inclusion among health care professionals who provide arthritis care.

We recently spotlighted the gaps in care and the shortage of health care providers who represent under-represented minorities by hosting a Diversity, Equity and Inclusion (DEI) Summit for rheumatologists, researchers and other health care professionals.

Several people presented their research in DEI that the Arthritis Foundation is funding. Among them were presentations on the racial and socioeconomic health impacts on children with juvenile arthritis, barriers to rheumatologic care for children with arthritis, shared decision-making so that more African Americans might benefit from total knee replacement and overall barriers to care for Blacks and Hispanics in the U.S.

Patient Trust and Understanding

Why is increasing diversity in health care important? Because Americans — and patients — are increasingly diverse, and patients need providers they can trust, said Sharon Dowell, MD, an associate professor of internal medicine at Howard University and rheumatologist at Howard University Hospital.

“I do think it’s extremely important that patients can see or have the option to see doctors that they feel they can relate better to,” said Dr. Dowell. She and Gail Kerr, MD, chief of rheumatology at the VA Medical Center and Howard University Hospital, spoke at the DEI Summit about models of collaboration to increase diversity in the rheumatology workforce.

Patients need providers who understand their particular challenges and circumstances, said keynote speaker Will Ross, MD, MPH, associate dean for diversity at Washington University in St. Louis School of Medicine. That became clear to him with one of the first patients he saw when he was a student in 1981 at Washington University. The hands of the patient, an African American man, were misshapen by rheumatoid arthritis.

“What was unique about this patient was he really didn’t have a provider who understood the difficulties he faced just going about the activities of daily living,” Dr. Ross recalled during his presentation at the DEI Summit. “He was concerned that everyone was looking at his hands and no one was really looking at him as a patient. That was a lesson, I think, more than the [hand deformities] from rheumatoid arthritis.”

Since then, Dr. Ross has been seeking to close the diversity and equity gaps in health care and advance community health, in part by creating and promoting programs to diversify the workforce by recruiting more medical students of color.

A Historical Problem

Non-white Americans are projected to outnumber white Americans in about 20 years, according to census data, and they already do in some states. At the same time, however, the number of medical students of color has not significantly increased in the past 30-plus years.

In the early 1900s, Black Americans had access to some 150-plus medical schools, but the Flexner Report of 1920 shut down most of the institutions, explained Dr. Kerr. There was a jump in numbers during the Civil Rights Movement, Dr. Ross explained, but the number leveled out for the most part since then.

In fact, fewer African American men started medical school in 2014 than in 1980, Dr. Ross said. In 2011, 7.3% of medical school applicants were Black compared with 54.6% white. Only 2% of professors of medicine are Black, and the number of African American medical school graduates is unchanged since he graduated in the 1980s. “This is abysmal. This is unconscionable,” he said.

The situation is similar among medical school faculty. While more junior faculty members are Black, the percentage of full professors has gone from 2% in the 1960s to only 4% by 2015. In rheumatology, “it was equally sobering.” A 2015 workforce study by the American College of Rheumatology found that only 0.8% of adult rheumatologists are African American and 8.5% are Hispanic, compared with 73.6% white.

Fewer Doctors, More Patients

Rheumatology is facing the same challenges as other medical disciplines: Rheumatologists are retiring, workplace demands have increased and health care systems don’t generally plan for succession as physicians in private practice used to do. At the same time, the number of patients each physician takes care of has grown as more people seek health care, the prevalence of rheumatic diseases has increased — especially among Black and Hispanic people — and the American population is aging and requiring more care.

Studies have shown that not only do Black and Hispanic people living with rheumatic diseases have more active disease and worse remission rates, but they are also less likely to receive care as promptly as white patients, potentially leading to poorer outcomes. So, there’s a large number of people with severe arthritis without access to doctors who truly understand that patient’s situation and challenges, particularly regarding social and systemic obstacles.

“How does this patient … get through their regular day? And who’s there to help them navigate care? This is particularly important when you see these lower rates of remission,” Dr. Ross said.

For the benefit of patients and for the benefit of the medical profession itself, increasing diversity is important. Academic institutions and health care organizations must commit to it, he said, in part by creating programs to encourage and make it easier for students — even as young as high school — to   pursue a career in medicine.

The Arthritis Foundation is making it a priority to help increase diversity among health care providers who treat people with arthritis. Our fellowship program encourages students of medicine to pursue rheumatology specialties and practice in under-served  regions of the country. And in 2021, the Foundation introduced a DEI grant program to attract under-represented minority medical students and residents to rheumatology, which is expanding.

Drs. Kerr and Dowell discussed other challenges and potential solutions that might help increase diversity in rheumatologic care. Since the Flexner Report shut down many Black medical schools, only a few remain even now, and historically Black colleges and universities have since produced a large proportion of Black physicians, Dr. Kerr said. Some potential solutions include more collaboration among academic, medical and other institutions to teach rheumatology, as well as financial and grant support, which the Arthritis Foundation is committed to.

Other solutions include better initiatives to promote and retain faculty in rheumatology. That includes health care providers from other countries trained in rheumatology, who often leave the U.S. due to challenges getting citizenship, desirable research positions and other factors, including racism, said Dr. Dowell.