Black Women’s Mistreatment In Health Care

*Editors Note — I recently graduated with a Master’s degree in Digital Journalism and Design. For my final research project, I focused on black women’s (and by proxy, black people’s) mistreatment in the health care system due to racism and unconscious biases. I thought it was something that would be of use beyond the scope of academia, so I’m posting it here. I hope you enjoy reading it. If you think it’s good, please leave a comment or share with others. Thank you for your time.*

Race affects every facet of American life; the type of education your children will receive, which families receive home loans, the transfer of generational wealth, and who lives and dies. As the internet magnifies the voices of minority communities, one facet of racism receiving more attention is the mistreatment of black patients within our health care systems.

Black women are at the forefront of this movement by sharing the unique challenges they’ve faced. These challenges result in doctors, who are often white, ignoring black women’s heavily expressed feelings of pain. Black women suffer from the negative effects of racial stereotypes and often feel dissatisfied with their medical treatment. It explains why black patients, and by proxy, black women, report better experiences with black physicians [1].

The treatment of black women, particularly when they’re pregnant, may also explain the newfound focus on black maternal health. Studies show black and white women have “one of the widest of all disparities in women’s health” as black women are nearly four times more likely to die from pregnancy complications than white women [2].

This paper will include first-person accounts from black women and their mistreatment by physicians in times they were most vulnerable. It has cost them their good health, mental stability, and in one case you’ll read about, their newborn’s life. Possible solutions are provided by experts within the medical field to combat these racial biases. In order to mitigate these effects, medical professionals need to improve their relationship with black patients. This topic illustrates the problem and creates awareness to prevent these situations from happening in the future.

Author’s Note

There are two main sources of information which form the bedrock of this paper. The first is the extensive research done to synthesize published studies, news, and peer-reviewed articles to form a comprehensive look at the overall treatment of black patients in health care. The second source comes directly from black women.

Social media was a major component in finding people willing to speak about their experiences. A number of participants sent messages expressing interest in helping with the project after I wrote a tweet explaining what I hoped to accomplish with my research.

The next stage was to put together a questionnaire. The goal was to allow people to share their experiences in a way which could really illustrate the human element behind the research. So, I asked participants, who at the time were both men and women, to share a time when they felt neglected while receiving medical treatment.

Four women, whose names were changed to respect their privacy, responded and it is their stories which form the other, and, in my opinion, most important, portion of this subject. Those women are Kimberly Jefferson, Gina Smith, Wilma Hayes, and Pia Smith.

The human element in the midst of these statistics is the important part of the research. Without their narratives, this paper becomes just another long list of seemingly abstract problems happening to nameless and faceless people.

Reporting On the Topic of Black Health Care

The treatment of black patients and the prevalence of internal biases by health care professionals have been covered extensively within the past year.

The University of Chicago Medicine published a study on racial bias in medical care across the world [3]. Vice published an article in February of this year where black women shared stories about doctors not trusting them and having to advocate for themselves [4]. Vox wrote about slavery and the impacts it’s had on America’s medical system in December 2017 [5]. According to Vox, that history “helps explain why black mothers are dying at alarming rates.”

The topic has been covered extensively from a myriad of different viewpoints. Researchers and journalists alike have studied the problem both from a scientific standpoint with hard facts and data as well as a story of human interest. Student organizations like White Coats Black Lives publish a yearly “Racial Justice Report Card” aimed at holding people accountable and showing ways health care centers can improve [6][7]. One issue with the coverage, however, is who is given the tools to write these stories.

Cynthia Greenlee brought light to this problem in her Columbia Journalism Review article “Coverage of maternal health threats overlooks black expertise [8].” Greenlee said the rush to cover maternal health is in danger of “perpetuating another racial disparity: a death of black experts in maternal health stories.” She points to the barrier of “expertise,” namely the idea reporters are only looking at advanced-degree holders as experts. There are others, like those who provide doula services, nurses, midwives, or the actual patients from these hospital rooms, who have a wealth of knowledge to share, but no reporter to share them with.

Complicated Pregnancy

It was supposed to be the happiest day of their lives. Kira Johnson, by all measures, had a perfect pregnancy. Her husband, Charles, says she never missed a visit and Kira was poised to birth a healthy baby boy. The delivery went as expected, but Charles was puzzled when he noticed her struggling in the recovery room. When he saw Kira’s blood filling her catheter, he knew something was wrong [9].

Charles alerted doctors to what he saw and they promised to order a CT scan. Hours went by before medical staff came to help. In the article for Atlanta’s NBC station, he said he told doctors “she’s beginning to tremble uncontrollably. She’s beginning to shake. She’s beginning to be in increasingly more pain. She’s becoming sensitive to the touch. There’s still no CT scan.” Doctors took Kira to another room and promised she would be back in 15 minutes. It was the last time he saw her alive [9].

In the U.S., black women dying during or after childbirth is not a rarity, particularly, when someone is ignored after notifying medical staff. Pregnancies can be complicated, and black women of any social class are going through similar struggles. According to a ProPublica and NPR collaboration article, black women are 49 percent more likely to deliver prematurely than white women, with black infants being twice as likely as white babies to die before their first birthday. Black women also have higher rates of C-section and are more than twice as likely to return to the doctor after the surgery. Finally, black women are twice as likely to have postpartum depression but less likely to receive mental health treatment [10].

Serena Williams has a similar story. Williams was concerned her history of blood clots would lead to a pulmonary embolism. It did. The embolism kicked off a series of health complications, leaving her bedridden for six weeks after giving birth. The tennis superstar says she experienced tension with her doctors. On Aug. 7, The Washington Post published an article containing further elaboration of Serena’s pregnancy journey. The Compton native mentioned times she was not taken seriously about her own health issues.

“She told a nurse “between gasps” that she needed a CT scan with contrast and a blood thinner, but the nurse thought Williams’s pain medication might have been confusing her. Despite insisting, Williams said a doctor still performed an ultrasound of her legs, which didn’t reveal anything, before sending her for a CT scan. ” [11].

The scan revealed several small blood clots in her lungs.

A History of Mistrust

Doctors ignoring black patients is a problem long experienced by the black community but seldom acknowledged outside of it. There’s a fragile relationship between medical professionals, who generally aren’t black, and the black people who rely on their care. According to the website BlackDoctor.Org, citing the 2013 U.S. Census Bureau, black people made up under four percent of practicing physicians, six percent of trainees in medical education, and seven percent of medical graduates [12].

Dr. Corey J. Williams offers an explanation in his opinion piece for The Hill, “Black Americans don’t trust our healthcare system — here’s why.” Dr. Williams says trust is a “foundational element to a therapeutic doctor-patient relationship” but acknowledges “the U.S. medical establishment has a long legacy of discriminating and exploiting black Americans.” It’s “deeply embedded in the collective consciousness of the community.” [13].

Dr. Williams refers to several periods of American history where doctors mistreated black patients. He starts with the Antebellum period of the United States, where “blacks were forced to participate in dissections and medical examinations,” moves on to the Reconstruction Era where “white American doctors argued former slaves could not thrive in a free society because their minds could not cope psychologically with freedom,” and then to the Civil Rights Era where “psychiatrists used the concept of schizophrenia to portray black activists as violent, hostile, and paranoid because they threatened the racist status quo.” [13].

There’s also the infamous Tuskegee Syphilis Study where doctors gave black men syphilis against their will and denied them treatment. Medicine, Dr. Williams says, has been “weaponized” against African-Americans [13].

A Disparity in Treatment

Much of America has changed, but some things remain the same. America isn’t far removed from time periods which significantly contributed to the health disparities black people face today. The numbers are staggering. Black people:

• are three times more likely to die of asthma than white people [14].
• have a 25 percent higher cancer death rate for all forms of cancer than white people [15].
• develop chronic diseases like diabetes, earlier in life [16].
• have shorter life expectancies by five years for middle-class black people and six years for black people living in “urban” areas [16].

According to the U.S. National Library of Medicine, there’s a simple explanation. The numbers are higher because black people are less likely to trust their doctors, and in effect, less likely to receive treatment or follow their recommended plans [17].

The study found people of lower socioeconomic statuses, people who typically have low incomes, education, and no health insurance, are generally distrustful of medical professionals. However, “the strength of these effects was modified by race [and] ethnicity.”

Pain Management

Kimberly Jefferson, hereinafter referred to as Kim, couldn’t believe it. Her five year battle with a failed liver was over. In 2018, after being put in a medically induced coma, she woke up with a brand new liver. She was overwhelmed with joy her long and exhausting journey seemed to be over.

She was originally diagnosed with liver issues in the summer of 2013. A diagnosis which kept her bedridden for nearly a month and almost landed her on the liver transplant list. During that summer, her body started to recover and once Kim was no longer eligible for a transplant, she opted to let her body recover on its own. Now, with a new liver, she hoped she’d be able to resume the life she lived before the diagnosis. Unfortunately, with her new liver came a new set of problems.

In September of this year, Kim was at home recovering from her surgery when she woke up with a strange pain in her leg. She called her transplant coordinator and was told to take Tylenol for the pain. The coordinator told her it was likely a side effect of the surgery. The next day, Kim felt excruciating pain in both of her legs and her right arm. Her mother and her sister called the ambulance. EMTs put Kim on a gurney and transported her to Tampa General Hospital. At this point, her stomach was swollen and similar to the size of a woman who was seven months pregnant. Doctors tried to relieve the pain with Morphine and Fentanyl but to no avail.

Kim says the medical staff was flabbergasted. She’d seen doctors from every corner of the hospital and no one could determine her issue. Kim took matters into her own hands. She researched her symptoms and eventually linked them to the anti-rejection medications she was taking for her liver. When she tried to inform doctors, they ignored her. Later, doctors ran tests and came to the very same conclusion Kim did, the side effects of her medication are what landed her back in the hospital.

As her hospital stay grew longer, Kim grew more impatient. Days would pass when she’d tell doctors about the pain she experienced and she’d, again, be met with deaf ears. But, the pain subsided, the swelling in her stomach went down after doctors performed an excruciating procedure draining more than five pounds of fluid from her stomach, and she was eventually allowed to go home. Once at home, she noticed she’d randomly lose control of her fingers. She wasted no time letting a doctor know about the problem but was met with heavy resistance.

On her next visit, the doctor was suspicious of Kim’s symptoms and questioned whether her story was true. “I don’t want you on pain meds unless we absolutely need them,” the doctor said. Kim had had enough. She decided to skip the pain management center entirely because she didn’t feel they were listening to her.

She says she had a frank talk about her treatment with one of the doctors. She demanded they treat her with more respect and take her serious when she went to them about her problems. Thankfully, she says she’s now receiving the best care she’s ever had and she’s happy with her doctors’ new attitude. It’s inspired her to be an advocate for other patients and she says she won’t stop until “every patient is treated with the best care no matter their race, gender, religion, or sexual orientation.”

In 2016, the Centers for Disease and Control (CDC) published a study regarding the relationship between racial biases and pain assessments between white and black patients. Researchers found black people were “systematically undertreated for pain relative to white Americans [28].” Two separate studies formulated the CDC report.

In the first study, researchers were examining people without medical training and how they perceived pain between different races. They found white people believed in biological differences between black and white people, “many of them fantastical in nature.” The research states these beliefs were “related to racial bias in pain perception.” In the second study, researchers took the results of the first study, extrapolating them to medical students and residents to see whether this affected recommendations for pain treatment. [28]

The second study reinforced what they learned in the first one. Researchers discovered “white medical students and residents who endorsed false beliefs showed racial bias in the accuracy of their pain treatment recommendations.” In other words, the racial biases of laypeople and medical professionals were quite similar, and these biases controlled the discrepancy in how medical professionals treat pain in black patients versus how they treat pain in white patients. [28].

These results back up a National Center for Biotechnology Information study Defining Racial and Ethnic Disparities in Pain Management, published in 2011. That study showed minorities in America consistently received poor treatment for acute and chronic pain. It noted the problem of “pain intensity underreporting” and said it is a “major contribution” to the pain management disparities [29].

Doctors Aren’t Listening

One of the most frustrating things for black patients is being ignored during medical treatment. According to the Journal of General Internal Medicine, only 36 percent of patients, regardless of race, have a chance to talk about why they came in for a doctor visit [18]. For patients with specialized care, that number dwindled to 20 percent. Most astonishing, even when patients get the rare chance to speak to doctors, doctors aren’t listening [18]. The study reports doctors only listen for 11 seconds before interrupting their patients [18].

A 2017 article from Dr. Danielle Ofri, Paging Dr. Vacant: Why your doctor isn’t listening to you, provides some insight. Dr. Ofri cites time pressures, fear of giving out bad news, or fear of making a mistake as reasons why doctors may not always pay attention to patient concerns [19]. Dr. Ofri also discussed the idea of internal biases, admitting she’s been guilty of her own biases when it comes to medical treatment of a patient.

“When a patient is a known complainer, [I] mentally downgrade what the patient has to say,” she writes. “[I] dismiss it as just another complaint and think that there’s nothing really wrong.” She says “internal biases are so deeply rooted they can be difficult to overcome [19].”

Dr. Ofri’s admittance to occasionally ignoring patients and recognizing her own internal biases is critical. If one combines her article with the CDC study, where medical students and residents have shown biases in pain management, a path to the mistreatment of black patients becomes clear. A biased doctor, who is also pressed for time, may not be interested in listening to what a black patient has to say. Therefore, they don’t allow them to fully express why they need treatment. It’s a combination that can lead to doctors mistreating a black patient in need.

Pia Smith was looking forward to having her first child but faced serious challenges early on. She thought she was suffering from normal pregnancy symptoms until she was forced to go to the hospital twice in the first two weeks for IV hydration. Her doctor diagnosed her with hyperemesis gravidarum, a term for extreme nausea and vomiting. Vomiting and nausea are symptoms one generally assigns to morning sickness. A doctor told Pia morning sickness typically shows up after six to eight weeks of pregnancy and ends after the first trimester. Pia had only been pregnant for three weeks.

Her first doctor assigned her home health care. She placed Pia on a 24-hour IV pump, but Pia’s symptoms continued to wreak havoc on her life. She was hospitalized five times within the first 18 weeks of her pregnancy. To make matters even more complicated, she was getting married and moving to San Diego which required a new address and new physicians.

Pia wanted to follow the health care plan she received from her first doctor. But, her new doctor was uncooperative. The new doctor said Pia was being “dramatic and emotional” and said her first doctor overreacted with the 24-hour IV pump. Doctors in her new office asked Pia if she was on drugs due to her severe weight loss and didn’t believe her issues were pregnancy related.

Eventually, a young Hispanic nurse came to her aid. She recognized Pia’s symptoms as hyperemesis gravidarum, the same diagnosis as her original doctor. The nurse referred her to a new OB-GYN in San Diego and Pia was able to receive the treatment she needed. At 37 weeks, Pia delivered a healthy baby girl.

Black Women and Pregnancy

Women like Pia, Serena Williams, and Kira Johnson all experienced the same treatment regardless of class and status. Johnson died because of the hospital’s failure to act urgently. Serena Williams described tension-filled moments with her own doctors. Pia nearly died during her pregnancy.

Nina Martin and Renee Montagne, of “ProPublica” and “NPR News,” respectively, published the report Nothing Protects black Women From Dying in Pregnancy and Childbirth. Montagne and Martin examined the increasing death rate of pregnant mothers in the United States.

They found CDC stats showing black mothers are three to four times more likely to die in childbirth than white mothers; a number which roughly equates to an astonishing 243 percent higher likelihood of death. Those numbers aren’t influenced by class, either [10]. A 2016 report with five years of data showed “black college-educated mothers who gave birth in local hospitals were more likely to suffer severe complications of pregnancy or childbirth than white women who never graduated from high school [20].”

Martin and Montagne were able to diagnose why this happens: racism. They pointed to a number of institutional factors such as the lack of insurance for black women and the historical segregation of hospitals, which are lower in quality than where white women give birth. They also discussed the unconscious biases of health care professionals.

In the more than 200 stories of African-American mothers that ProPublica and NPR have collected over the past year, the feeling of being devalued and disrespected by medical providers was a constant theme. Repeatedly, black women told stories of medical providers who equated being African American with being poor, uneducated, noncompliant and unworthy. “Sometimes you just know in your bones when someone feels contempt for you based on your race,” said one Brooklyn woman who took to bringing her white husband or in-laws to every prenatal visit [20].

Those biases can result in the loss of a life.

Gina Williams was expecting her second child. But, two weeks before she was due to give birth, cramps crippled her. She thought the baby was coming early so she scheduled an appointment with her doctor that Friday. The hospital told her it was nothing and sent her home.

On Saturday, Gina thought her water had broken. She went to the hospital and again, was told there was nothing to be concerned about. On Sunday, the pain returned even more forcefully than previous days. She’d had enough. Gina went to see her doctor and he gave her news no mother should ever have to hear.

The doctor told Gina she’d been in labor since Friday and her water had, as she suspected, broken on Saturday. Because there was no amniotic fluid in her body, her baby suffocated in her womb. Unfortunately, Gina still needed to deliver the child vaginally because a C-section wasn’t an option.

Issues With Mental Health Treatment

Black patient mistreatment doesn’t just extend to physical medical issues or pregnancy. It covers mental health issues, too.

In 2016, a doctor prescribed Lexapro to Wilma Hayes for her anxiety and depression. Wilma told her doctor the medicine caused her to have adverse side effects like exhaustion, restlessness, excessive weight gain and a lowered sex drive. She wanted her medication switched but her doctor insisted her medication didn’t cause the symptoms.

By 2017, Hayes had enough. She told her doctor that at the behest of her therapist, she would find a psychologist. The doctor, magically, had a change of heart. “All you had to do was let me know your medication wasn’t working,” she said. Hayes got her wish. She was taken off Lexapro and switched to Wellbutrin. The doctor advised her to start the medication immediately but Hayes was troubled by her newfound insistence.

She spoke with a friend about the situation, and her friend reinforced the doctor’s instructions. Hayes started the medication and benefitted immediately. She lost the weight she’d gained, slept better and had a renewed sex-drive. Unfortunately, she also noticed her “highs” were quite high and her “lows” were very low. When she spoke to her doctor, she said her mood swings were the result of the stress. She told her not to worry.

In June 2017, things hit rock bottom. Hayes broke up with her partner and says “everything felt like a tailspin.” She was bedridden for a week and had suicidal thoughts. She spent five days in a psychiatric facility. While there, the psychiatrist assigned to her caseload told her that her medications had been mismanaged. Hayes said she tried on numerous occasions to inform her original doctor what was happening, but her doctor dismissed it. She felt what happened to her could’ve been prevented if only the doctor had listened.

Dr. J. Corey Williams says this falls in line with the statistics of black people and mental health. “Black Americans are less likely to receive certain medicine for their conditions compared to whites with the same condition,” he writes. He also mentions black people usually receive “older medicine with worse side effects.”

How to Fix Unconscious Bias

There are several ways to deal with unconscious bias, caused by racism, in the healthcare industry. The first step to fixing the problem is addressing it.

Monique Tello, MD, MPH, wrote Racism and discrimination in health care: Providers and patients in 2017. Tello says “we need to be open to identifying and controlling our own implicit biases.” Furthermore, “we need to be able to manage overt bigotry safely, learn from it, and educate others [21].”

David R. Williams, Ph.D., M.P.H. and Toni Rucker, Ph.D., published Understanding and Addressing Racial Disparities in Health Care in the summer of 2000. They believe stopping this problem goes beyond just addressing biases and calling out bigotry. Their article says the health care system can address treatment disparities with “improved data systems, increased regulatory vigilance, and new initiatives to appropriately train medical professionals and recruit more providers from disadvantaged minority backgrounds [22].”

Researchers published other methods in the article Reducing Racial Health Care Disparities: A Social Psychological Analysis. For starters, they don’t believe addressing just the physicians or the system is good enough. Fighting against bias on an individual level with coursework is limited “unless they have strong institutional support [23].”

Next, they believe even if physicians can recognize racial biases “they may not recognize how their personal beliefs and actions contribute to these disparities.” They acknowledge implicit biases are “acquired over time” and can be difficult to unlearn [23].

Their suggestion is for physicians to develop techniques and skills “to limit the impact of a physician’s implicit bias [23].” This would include treating patients as individuals, as opposed to a representative of a racial group, patient-centered communication, and building a better relationship with black patients.

The above suggestions are acceptable methods of combating racial biases but, frankly, it’s not enough. This discussion isn’t centered on a few doctors making bad decisions or a few patients who feel ignored. It’s a systemic problem requiring a complete rebuild that starts from the first day of class in medical school. It’s a need students themselves have already brought up.

In 2017, N. Jia Ahmad and Marc Shi, MSc, were third-year medical students at John Hopkins University in Baltimore. Ahmad and Shi wrote about their experiences of starting medical school months after the death of Freddie Gray, a black man in Baltimore who died suspiciously while in police custody. They said they’d learned about cultural competency and professional implicit bias throughout their student careers but “these lessons [are] insufficient to create a cohort of medical professionals who can transform understanding into action [24].” They believe medical schools should find a long-term solution to the problem which evaluates “skills that will equip graduates to combat racism and structural oppression.” Furthermore, they want those areas to be “enforced as thoughtfully and rigorously as our traditional clinical training [24].”

In May 2018, the American Academy of Family Physicians published an article by Venis Wilder, M.D. on what medical schools can do to combat racism. Dr. Wilder says medical schools need to “have a group distinct from the school administration that can provide a critical lens from within [25].” She mentions a student-led group, White Coats for Black Lives. According to the website, White Coats for Black Lives is a “medical student-run organization born out of the National White Coat Die-In” in December 2014 [6].

The group is interested in dismantling racism and promoting the health of people of color. White Coats has three goals: foster dialogue on racism as a public health concern; end racial discrimination in medical care and; prepare future physicians to be advocates for racial justice. The group has chapters in at least 21 states. Their website also provides instructions and help for students who wish to start a chapter at their school. Lastly, the group published their Racial Justice Report Card in 2018. It’s a report card which “consists of 15 metrics” evaluating an “academic center’s curriculum and climate, student and faculty diversity, policing, racial integration of clinical care sites, treatment of workers, and research protocols [7].”

Schools interested in producing better medical professionals may want to take a cue from coursework at Harvard Medical School. In 2017, Greta Friar detailed what Harvard Medical instructors were teaching students to reduce implicit bias in a course from 1999–2009. Friar said the course focused on “culture humility instead of cultural competency [27].” The difference is cultural competency focuses on how to treat patients. Some researchers believe it’s an incorrect model which may reinforce stereotypes. Instead, the Harvard course “emphasizes self-awareness as a way to identify and overcome cultural conditioning [27].”

The course focuses on students learning self-awareness and creating an empathetic environment for students to learn from each other. For the self-awareness portion, students were asked to look at their own backgrounds. Next, students needed to see their own bias and “how they learned them in the first place.” Students creating an empathetic environment was also key.

In order to create a safe space for open dialogue, the instructors created a set of ground rules for the class. Students were told not to blame or shame each other — or themselves — as they admitted their biases. Class discussions were kept constructive and confidential. The authors believe rules like these are necessary to combat a thorny problem in medical culture: fear of failure or being poorly perceived, which may prevent medical students and professionals from speaking openly about the biases they want to overcome. [27]

The course also required students to keep journals, participate in discussions, and actively de-construct their own identity.

Conclusion

Unconscious racial biases in the health care system are a wide-sweeping problem. It will likely require a complete overhaul which stretches all the way back to medical students’ first day on campus. Doctors will need to work harder to understand how their biases affect the way they treat black patients and actively work to ensure all patients are being afforded equal care. Still, it’s inspiring to see so much activity around racial biases in the system, particularly, student-led movements like White Coats Black Lives who are doing their best to hold their industry accountable.

There’s a chance this newfound attention could be the beginning of a transformation for black health care. The community will have to work together to enforce these changes. This newfound visibility will require the sort of assessment America, which as a long and sordid relationship with black people, has been unwilling to make. Only time will tell.

References

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[10] Martin, N., & Montagne, R. (n.d.). Nothing Protects Black Women From Dying in Pregnancy and Childbirth. Retrieved from https://www.propublica.org/article/nothing-protects-black-women-from-dying-in-pregnancy-and-childbirth

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[19] “Paging Dr. Vacant: Why Your Doctor Isn’t Listening to You.” The Globe and Mail, The Globe and Mail, 17 May 2018, www.theglobeandmail.com/life/health-and-fitness/health/how-to-improve-communication-between-doctor-and-patient/article33875386/.

[20] New York City Department of Health and Mental Hygiene (2016). Severe Maternal Morbidity in New York City, 2008–2012. New York, NY.

[21] Tello, Monique. “Racism and Discrimination in Health Care: Providers and Patients.” Harvard Health Blog, Harvard Health Publishing, 12 Jan. 2017, www.health.harvard.edu/blog/racism-discrimination-health-care-providers-patients-2017011611015.

[22] Williams, D. R., & Rucker, T. D. (2000). Understanding and addressing racial disparities in health care. Health care financing review, 21(4), 75–90.

[23] Penner, L. A., Blair, I. V., Albrecht, T. L., & Dovidio, J. F. (2014). Reducing Racial Health Care Disparities: A Social Psychological Analysis. Policy insights from the behavioral and brain sciences, 1(1), 204–212.

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