It’s the summer of 2020 and people of privilege are grappling with the reality that major social institutions (like our police forces) unfairly and disproportionately harm people of color. As the Black Lives Matter movement gains widespread adoption, many institutions are examining their internal policies and culture in an attempt to eliminate systemic anti-Black racism. Even historically recalcitrant organizations like the Washington NFL football team, which has refused to discuss changing their name and mascot over the previous decades, has announced that they will do exactly that. Beyond symbolic gestures, companies and individuals seem genuinely ready to examine themselves on a deeper level. In places as unlikely as the ski industry, very honest discussions are occurring. In an open letter to employees on June 2, Vail Resorts CEO Rob Katz writes, “Explicit and implicit racism, sexism or any kind of discrimination have absolutely no place at Vail Resorts … I am also confronted by the fact that our Company and our sport are overwhelmingly white, with incredibly low representation from people of color.”
How is health care involved in this movement?
Radiology Department chair, Satoshi Minoshima, M.D., Ph.D., recently made the connection clear for staff and faculty. He explained that the World Health Organization defined “health” in 1948 as a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity. “By this definition,” he emphasized, “as we observe the systemic racism in our country, we must understand this as a significant public health issue.” Blacks and other people of color experience physical, mental and social harm due to racism.
Here at University of Utah Health, in a state known to be overwhelmingly white, our leadership is working to remove systemic racist practices that discriminate against Blacks and all underrepresented people and to build a system with increasing diversity, inclusion and equity. There is a phrase for this: anti-racism.
What is anti-racism?
Thought leaders in our country have noted that the term “not racist” is passive. Being “not racist,” is not aspirational; it is often used to simply defend “business as usual.” Ibram Kendi, Ph.D., the leader in anti-racism scholarship in the U.S. goes so far as to state that the term “non-racist” has only one use in English: to defend our racist actions.
That’s why the term “anti-racist” is used to describe active efforts to remove racism from our culture. In his post “Towards Anti-Racism as a Shared Value,” José E. Rodríguez, M.D., the associate vice president for Health Equity, Diversity, and Inclusion (HEDI) at University of Utah Health, explains that “An anti-racist institution is one that thoughtfully examines every process of inclusion in the institution (admission, staff hiring, faculty and resident recruitment, etc.) and eliminates any system that appears racist or permits results that could be interpreted as racist.”
By focusing on institutional processes, Rodríguez is affirming one of the basic tenets of anti-racism: That beyond overt racism, systemic racism is pervasive in our society and must be removed. Systemic racism can be found in the laws, policies, procedures, and customs that exclude certain groups from positions of privilege and power. “On a daily basis, you don’t see as much overt racism as you did 70 years ago,” asserts Rodríguez, “but the Black Lives Matter movement is drawing attention to systemic racism, where people are being taught subtle and not-so-subtle ways of relating to Blacks and other people of color that keep them down.” News headlines focus on the racist actions of the police that are literally killing unarmed Black citizens around the country, but Rodríguez points out that every system and organization, including ours, needs to take this moment in time to root out systemic racism.
The University of Utah has invested in three major positions to help us become an anti-racist university. At the top is Vice President of Equity, Diversity, and Inclusion Mary Ann Villarreal, Ph.D. She provides leadership for equity, diversity and inclusion initiatives across the university’s main and health sciences campuses. On the Health Sciences campus, we have Associate Vice President José E. Rodríguez, M.D., who is a practicing physician and full professor in the Department of Family and Preventive Medicine. Also within the School of Medicine is Associate Dean for Health Equity, Diversity, and Inclusion Paloma F. Cariello, M.D., MPH, who is also an associate professor in the Division of Infectious Diseases.
To engage in anti-racism, we must examine the three principles found in the name of their office: diversity, equity and inclusion.
“Diversity is simply a number while equity and inclusion are behaviors,” states Yoshimi Anzai, M.D., MPH, a professor in radiology, associate chief medical quality officer at University of Utah Health and the chair of the Committee of Diversity, Equity, and Inclusion at the Radiological Society of North America. “As you examine your group, you determine by sheer numbers how diverse you are in terms of race, gender, age or any number of factors.”
There are many reasons that growing diversity should be a deliberate goal. First, from a moral perspective, accepting diversity upholds what most moral systems call the “golden rule,” that is, treat others as you would like to be treated. Second, from a political perspective, it aligns with the reality of the U.S.A. as an immigrant nation. Even though our country was established by white European colonizers who pushed aside a non-white native population and built itself with the labor of enslaved blacks, the nation has nonetheless accepted wave after wave of Irish, German, Asian, Eastern European, African and South and Central American immigrants. We have acknowledged some of the errors of our founding laws by later abolishing slavery and granting the right to vote to white women, and to people of color over 50 years later. Thus, diversity is a political value of our nation, both in our de facto openness to immigration and as written into our laws granting protection and participation for women and people of color.
A third reason diversity is essential: it can improve how a business performs. Anzai shares several studies that demonstrate the positive impact of diversity. A recent study looked at 1,700 different companies across eight different countries, with varying industries and company sizes, and found that companies with more diverse management teams have 19% higher revenue due to innovation. Other studies show that more diverse organizations have higher morale, increased creativity, better critical thinking, and better reputations. Closer to home, a landmark Institute of Medicine study in 2004 showed that diversity among medical professionals is associated with improved access to care for racial and ethnic minority patients, greater patient choice and satisfaction, better patient-clinician communication, improved medical student learning and higher cultural competence of health professionals.
So, diversity can help us better care for patients. Rodríguez affirms that having health care providers of color serve patients whose culture is familiar results in better health outcomes. “Population parity is an intermediate goal,” Rodríguez states. “Fourteen percent of Utah is Latino, so it would be great to have 14% of our graduating medical students be Latino, too,” he explains. “But medical students often move to practice medicine outside the state where they were trained, so our long-term goal should be patient-provider concordance,” he clarifies, “and keeping an eye on making sure that our provider mix, including staff at all levels, is roughly on par with the patient mix we serve.”
As Anzai states, diversity is simply a measure of numbers and not a measure of participation or access to health services. Take the historical United States: in some areas of the plantation south, Blacks greatly outnumbered whites, yet that was not a healthy diversity by any stretch. In fact, laws were set in place to make sure that participation and equality were explicitly forbidden. Ben Hecht writes succinctly in a recent Harvard Business Review article, “From 1619 to 1965, this country had laws, policies, and practices—from slavery to Jim Crow to redlining—that legally separated white and Black people in an attempt to maintain a white supremacist society.” This ugly 350-year history shaped who we are and the society we live in. The Civil Rights Act of 1964, for all the good it accomplished, did not abolish racism or the thousands of legal, corporate, and cultural systems that had developed within a framework where people of color were explicitly viewed as lesser citizens. Many white people are just now realizing, 55 years later, that systemic racism and unconscious bias (as well as conscious discrimination) are alive and well.
Our society is the result of decision-makers at banks, government and business doing their work in an environment where bias and discrimination run mostly unchecked. People of color have less opportunity, which leads to lower educational levels, less income, more poverty and even lower life expectancy. In King County, Washington, there is a 10-year life expectancy gap between zip codes with predominantly white and predominantly black citizens. Racism is indeed a health issue! In fact, higher disease burdens and poorer health outcomes for Blacks and other people of color have remained virtually unchanged since they were first widely accepted by the medical establishment. “We have tried everything to eliminate them, yet they persist,” states Rodríguez. “Health disparities are the medical manifestation of systemic racism.”
This is the definition of inequality. But let’s be careful to not conflate equality with equity. “Equal under the law” is not equity. Rodríguez explains, “If we treat everyone the same, that is equally, then we’ll get the status quo. But if we use equity, that is, meeting specific needs, then we’ll get diversity.” Equity, in other words, is about leveling the playing field, eliminating barriers for Blacks and other underrepresented people to reach the same level as people in the white majority.
In the workplace, equity starts when Black candidates and candidates of color are actively recruited and interviewed for job openings. Targeted recruiting acknowledges that underrepresented people must compete in an environment of systemic racism that misrepresents the qualifications and quality of work of certain people. Targeted recruiting of underrepresented people is anti-racist because it seeks to overcome the systemic racism that makes it difficult for underrepresented people to be interviewed, let alone be hired.
Of course, no one at the university is suggesting that people of color be interviewed and hired simply because they belong to an underrepresented group. Strong qualifications for a job will always be the cornerstone when it comes to our workforce. The point is to try to give everyone possible a shot at interviewing, not just those who have obvious advantages in the job market.
Equity also impacts conversations about merit. Anzai asks, “Do you really know how good someone will be in a job?” Certainly, there is an element of guesswork in judging candidates for a position. But what about objective measures like test scores? “Even scores for incoming residents can’t really predict how they’ll perform,” Anzai notes. “Every person surprises us in one way or another and we have to be very skeptical of judging relative merit between people.” Anzai echoes the belief of most thought leaders in the field of racial equity: Hiring decisions are driven more by our comfort level with candidates. This comfort level is determined by the millions of unspoken biases we learn over time, from preferences on a person’s body language to associations the color of their skin might conjure in our minds.
This is where the concept of equity comes into play. Since underrepresented people often do not have access to the same money, education, and opportunities (even the same benefit of the doubt in others’ minds), equitable practices seek to make up for these obstacles. Along these lines, Rodríguez argues that the problem of believing in merit is more insidious than we realize. “The myth of meritocracy is a completely racist idea,” he claims. He points to the founding of our country as evidence: “These men claimed to make a nation based on the fact that everyone is created equal, but women and people of color were made subservient to them. The result is a fantasy of equality, where we pretend to assume that everyone has equal opportunities and an equal chance to pull themselves up by their own bootstraps, but nothing could be further from the truth.” Rodríguez’s point is that a meritocracy only makes sense when you compare people of equivalent opportunities—those with similar backgrounds, education, income, etc. Since there is such a disparity in our country, especially along racial lines, there is no good way to use “merit” as a guiding principle.
Rodríguez is adapting our hiring efforts to embrace equity and also ensure that they are outcome-driven. “Instead of reimbursing departments for travel costs when interviewing potential faculty members of color, we want to provide a financial incentive when they actually hire underrepresented people.” Rodríguez sees this as a good example of a policy that distinguishes a subtly racist system from one that this anti-racist. “At best, improperly aligned incentives reward intentions, not outcomes, and at worst they perpetuate a system where we can give lip service to diversity but not do anything substantial,” he explains. He uses the analogy that our institution, and really any system, is like a computer, which will only do what you program it to do. If you program it to interview people of color, that’s all it will do. If you program it to hire people of color, that’s what it will do.
Racial equity is built upon an acknowledgment of the imbalanced, unjust, and unequal Black experience in our country. Inclusion offers a way towards balance; it is the opposite of exclusion, the opposite of segregation.
Rodríguez insists that inclusion efforts during recruiting have an incredible effect. He recounts his own experience here in Utah. As a physician dedicated to working with Latinx patients, he was having trouble seeing that his perspective was welcome until the division chief took him to the Redwood Clinic and he saw the racial diversity in the patient population. Yet the university’s recruiting showed off areas like the east bench, good restaurants, and the mountains. It wasn’t until another physician in the Division of Family and Preventive Medicine, also Puerto Rican, struck up a personal correspondence with him and invited him for dinner at her house that he could envision himself feeling like the move to Utah was a fit for him.
At its heart, inclusion is about making people feel welcome, bringing them to a place of psychological comfort.
Sadly, there are myriad ways we make people feel unwelcome. From surrounding ourselves with people like us to not-so-subtle looks of disdain, humans are very good at silently projecting their feelings. Anzai, as a Japanese American woman, has at times felt a Utah culture that undervalues professional women, particularly women in color, as compared to other more diverse cities that she had lived, such as Los Angeles, Seattle and Ann Arbor, Michigan. She notes that small but palpable micro-aggressions are discouraging for women to thrive in the STEM field.
This is why the term micro-aggression has been coined. To the aggressor, an action might seem small (micro) or unnoticeable, but to the victim, they are cruel and hurtful. Many people dismiss micro-aggressions as a sign of a soft and too-easily offended culture, but when understood in the context of a society attempting to become anti-racist, they make more sense. The point is that underrepresented people have a way to signal to people in the majority when inclusivity has given way to exclusivity.
Anzai and Rodríguez both recommend unconscious bias training as a good way to begin to recognize how each of us carries unspoken biases for and against certain groups. As we become aware of our own unconscious bias, we can strip away the little mental acts of racism that keep us from appreciating each person as a unique individual. Once biases are identified, constant effort must be exerted to eliminate them. As Rodríguez points out, “Knowing you have them is kindergarten-level knowledge. Correcting them is college-level knowledge. Eliminating them is anti-racism.”
“A problem we encounter in academic medicine is that underrepresented groups are seen as somehow deficient,” Rodríguez states. “When first working with a person of color or a woman, the traditional response is that this person somehow needs to be ‘fixed.’ In fact, they are the grittiest people you’ll ever meet. We have to stop falsely assuming deficiencies and start seeing all of the proficiencies they bring.” His point is that we should recognize that what makes a great candidate is the ability to get up after we are pushed down. “Our Black colleagues, due to the sheer volume of obstacles systemic racism has placed in their path, have expertise in this area,” he asserts. “We cannot overstate the importance of this skill in becoming a successful employee/faculty member.”
Anti-racism requires a personal, mental commitment. We must recognize that we are taught anti-Black racism by the culture all around us, but that we can unlearn racism. We must not only recognize the problems we perpetuate but maintain the conviction that we will be better if we respect one another. This is a change of mind, being open to admit that the things we’re used to contain implicit bias; it’s a change of heart, wanting more than just comfort for ourselves but also equity for underrepresented people; and it’s a change of culture in that anti-racism becomes a value shared by everyone in our workplace.
The good news
Dr. Omowunmi Temitayo Ajibola moved to the United States from Nigeria when she was 8 years old. She went to a racially diverse medical school in upstate New York and encountered an even more internationally diverse internship and residency in New York City. “I felt like I was a minority because I was American,” she laughs. In 2020, Dr. Ajibola chose the University of Utah for her Interventional Radiology fellowship.
It’s no secret that Utah is not very racially diverse. In the 2010 census, 88.6% of the state was reported to be white while just 1.6% was African American. But these data did not deter Ajibola. Interventional Radiology fellowships are infamous for being demanding and tough on the body, mind, and spirit. “I remember encountering a very warm environment when I interviewed here,” Ajibola recalls. This made all the difference as she considered a difficult few years ahead regardless of where she would be. She also noted the natural advantages of our health system, being the only academic medical center in the intermountain west: the mix of cases and volume of cases are excellent. But what stuck out in her mind was the positive, welcoming culture of the team here.
“You have to create a welcoming environment to attract diverse attendings,” she states. “As a person of color, I have to walk in and feel like I’m welcomed and not judged. People of color pick up on things that are real. There are lots of places that talk the talk but don’t walk the walk.”
Ajibola was also struck by the gender diversity in our program, including the fact that the section chief, Karen Brown, M.D., is a woman. “We have two strong women attending physicians and people of color throughout the department,” she notes. Diversity in all its forms is important.
The Department of Radiology and Imaging Sciences is actually a national leader in gender diversity within leadership positions. Seven of eight section chiefs are women, a proportion far above what you encounter in other healthcare systems. We also have a higher percentage of women physicians in the department than the national average for radiology departments. The department chair, Minoshima, is committed to diversity efforts, and while he is proud of the progress in increasing gender and Latinx diversity, he acknowledges that recruiting Black radiologists remains a challenge. “We have to be proactive and strategic in reaching out to medical schools and trainee programs,” he says.
Ajibola agrees that people of color must be encouraged at much earlier stages in their careers. “There are not enough efforts to recruit at the college level, particularly in historically Black colleges,” she points out. At the other end, once a person of color is hired, they will stick around only if there is a culture of support and a community that values diversity.
Thankfully, Senior Vice President for Health Sciences Michael Good, M.D., is already moving our health care institution forward in several ways. In a recent post, he details how we are using the momentum of the Black Lives Matter movement to do real anti-racism work, including anti-racism audits in every School of Medicine department, a $1 million medical school scholarship program to advance a diverse student pool and a new Anti-Racism Commission to engage in culture change efforts.
Together, with a concerted effort, we can begin our journey toward becoming an anti-racist organization. Rodríguez reminds us that it will take time and effort: “It took our entire history to become the racist institution that we are—so we must commit to the long journey ahead to root out systemic anti-Black racism at University of Utah Health. Only then will we be able to say that we are becoming anti-racist.” In this journey, we all, individually, need to be accountable for achieving the goal.