Why do People of Color need culturally competent healthcare?
“We are the same under the skin…we are all the same inside” is a comment we received from someone in the early months of Spora Health’s launch and there are still many folks who don’t understand why creating a primary care system specifically designed for people of color is necessary. Some have complained that it’s a case of ‘separate but equal’ or even reverse racism. This is something we want to address directly, because while the people we built this for understand why the need exists, there are many people who don’t get it.
We first want to clear up a common misconception–we treat all people regardless of their race. With that said, one of our main differentiators is that every one of our providers has been trained in health equity and specializes in working with Black patients. Our technology and proprietary machine learning algorithms are designed to understand the specific health outcomes of Black patients–without baking in all of the problematic biases that so often show up in some of the most advanced technologies being developed today. The statement “we are all the same inside” lacks nuance. The color of one’s skin is not the reason that people of color need care specifically for them- racism is. Our existing medical system is still rife with problematic behaviors and assumptions and it is time for Black people to have a medical home where they can be confident that every single affiliate of Spora Health is committed to changing that.
Part of understanding why culturally competent care is needed means understanding our current medical system and how it affects patients of color. Countless medical decisions are designed with white people as the default and this harms other ethnic and racial populations. This sort of disparity starts the moment babies enter the world; all newborns go through the APGAR test which looks for birth injuries. The “A” in APGAR stands for ‘appearance’, and if you look at the criteria for scoring a baby’s appearance, the colors listed are either blue or pink. Because a Black baby will not present as “blue” or “pink” it can be more difficult to properly assess its status and identify the need for resuscitation. By not taking racial variances into account, young clinicians begin caring for the littlest patients with a major gap in knowledge that can be dangerous.
Conversely, active harm is also done in medical scenarios where it’s protocol to factor in race when diagnosing an illness. A test to estimate kidney function, called eGFR or estimated Glomerular Filtration Rate, systematically overestimates proper functioning of the kidneys for Black patients. When a provider tests a patient for kidney function, they test serum creatinine and put its value into an algorithm that adjusts for race and sex–resulting in a systemic overestimation of kidney function for Black patients. This leads to delayed diagnosis and more severe progression of disease prior to treatment for Black patients.
Here are just a few more examples of the very real types of institutional and interpersonal racism that Black Americans face in healthcare:
A machine learning and healthcare expert found that an algorithm used by Optum wasless likely to refer black people than white people who were equally sick to programmes that aim to improve care for patients with complex medical needs.
One study on both verbal and non-verbal communication found that black patients consistently experienced poorer communication quality, information giving, patient participation and participatory decision-making than white patients.
A study in the Journal of Vascular Surgery has concluded that African Americans, and African American men in particular, are at a higher risk for preventable amputations.
These health inequities were woven into the fabric of American society long before we were a country, so much so that most people don’t even recognize that they still persist. If you were a person of color, Indigenous, a woman, or someone who didn’t own land- you were excluded from almost every kind of activity that would lead to your voice being heard or your own economic advancement, compounding over generations.
If you are not a Person of Color, you’ve probably never experienced or had to think about how any of these contemporary medical scenarios might be different for someone who was a different race or ethnicity than you. But this system still exists and it needs to change.
Historical Precedent for Spora Health
Those who were excluded didn’t just sit around waiting for someone to bestow full rights to oppressed peoples. They created institutions that have cultivated some of America’s greatest leaders. Cheyney University was the first Historically Black College and University (HBCU) created in 1837, before the abolition of slavery. The creation of HBCUs came out of a need for Black people to become educated in a society that denied them their right to an education. Today, HBCUs are essential because Black students still lag behind in educational outcomes due to institutional and systemic racism, and these colleges and universities specialize in meeting Black students where they are, surrounding them with love and lifting them up.
HBCU students succeed because they receive an education that is designed to meet the specific needs of Black students. HBCUs produce exceptional outcomes and are the main pipeline of African American applicants to medical school, with Xavier University and Howard University accounting for 92% of the nation’s graduating medical students.
Similarly, the first women’s college, Wesleyan College, was established in 1836, propelling women to leadership roles and expanding the concept of what was possible for all women long before they could vote or have a credit card. These institutions were created precisely because women were barred from almost all universities and the founding members of women’s colleges found that to be unacceptable. What emerged from that is a culture that led graduates of women’s colleges to break down barriers and shape culture. A single-sex education still has value in a society that has become more inclusive of females, even as the gains women have seen are lagging. In 2020, women still only earned 84 cents for every dollar that a man makes. Girls consistently score lower in STEM assessments during their primary education. Those outcomes start to narrow when someone attends a women’s college. Women’s college graduates go on to receive graduate degrees at almost twice the rate of their counterparts at public universities. In the workplace, a third of the Fortune 1,000 female board members graduated from single gender institutions even though women’s college graduates are only 2% of the college graduate population. The need for women’s colleges still exists because women have not achieved parity in most of the centers of power, be it politics, business or academia.
Using single-sex education as an example of a historical and contemporary specialized service that functions is crucial because we live in an intersectional world. Intersectionality was conceptualized by Kimberlé Crenshaw as the interconnected nature of social categorizations such as race, class, and gender, regarded as creating overlapping and interdependent systems of discrimination or disadvantage. In essence, being a woman is oppressive and being a person of color is oppressive and one cannot separate out those identities, they are interdependent and they cannot be separated from one another. By carving out a space for oppressed groups to come together in areas where they have either been excluded or face disparities, Black people and women have been able to overcome some of the barriers in place. At Spora Health, we are laser-focused on treating all facets of a patient, be it their race, gender, sexuality or environmental needs by providing culturally competent care. We also know that we are not treating a Black patient as a monolith, we are treating them as a Black female or a Black hearing-impaired patient that speaks French at home.
When someone asks why Black people need primary care that is specifically for them, I remind them that there is a ton of precedent for this. For centuries we have had healthcare practices that only serve females and people with special environmental needs. More recently, the Founder of CityMD has gone on to create Rendr, a multi-specialty medical group serving Asian Americans. History has shown us that when minority groups have their own spaces outside of the white heterosexual-normative patriarchy that are well funded, and committed to the people they serve- those populations can thrive.
The Spora Difference
Spora Health is creating a space where Black people can trust that their providers intimately know the needs of their community and specialize in the care of Black patients. Racially concordant healthcare (where the race of the medical provider and the patient are the same) has been shown to reduce disparities for Black patients in a number of ways. Black patients who have a Black healthcare provider have a higher rate of utilization of needed healthcare services. Black newborns mortality is halved when they are cared for by a Black physician. This is not to say that providers are deliberately treating one patient differently than another based on their skin color. It indicates that in a world where the default patient is a white male, providers of color see themselves and their family in Spora patients and narrow the gap in care. While not all Spora Health providers are people of color, many of them are, which creates an opportunity for patients to see someone who looks like them even if that is not readily available in their community.
Another way that Spora Health ensures culturally competent care is through our proprietary training. Before a Spora provider begins working with patients, they go through more than 10 hours of health equity training. Our providers learn about the specific biomedical needs of our patients and how they can present differently at times. For example, depression can be expressed somatically by some African American men, leading to elevated rates of misdiagnosis. We talk about chronic disease and proven methods to initiate and maintain behavior change with patients in a world that often places blame on patients of color. The training also covers evidence-based frameworks to overcome biased behavior because many of the disparities in medicine are rooted in provider behavior. Finally, we discuss behavior change for our providers and how they can most effectively implement some of these strategies into their practice.
Another person commented on our social media pondering, “Do they have white staff employed? White healthcare providers? If so, I wonder how they feel about this..” As a white staff member, who has worked with some of our white healthcare providers, I can say that I am filled with pride seeing how dedicated our whole team, including other white staff members and providers, are to removing disparities in care through every angle of primary care and centering the voices of our patients because at the end of the day, this work is not about how white people feel.
We have a lot of work to do at Spora Health in the quest to achieve health equity for Black folks and People of Color more broadly. It will take more than one company to change a struggling healthcare system, but we are ensuring that we are leading that charge and centering Black patients while we do it.
More resources to keep learning
Students’ perceptions on race in medical education and healthcare
What Doctors Aren’t Always Taught: How to Spot Racism in Health Care
Challenges and Prospects for Disaggregating Health Data among Non-Hispanic Whites
“White Privilege: Unpacking the Invisible Knapsack” by Peggy McIntosh
Resources for White People to Learn and Talk About Race and Racism
Me and White Supremacy Workbook by Layla F. Saad
