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Now that you have spent some time reflecting on equity, diversity, and inclusion, let's dive a bit deeper into how our social identities, positionality, and privilege(s) intersect.

Positionality

Positionality refers to the personal values, views, and location in time and space that influence how one engages with and understands the world. It is wrapped up in the dynamics of power and privilege. For example, your gender, race, class, and other aspects of your social identities influence and inform how you move through the world, what knowledge you produce and value, and the biases through which everything you say, think, and do, is filtered, intentionally or otherwise.

Moreover, positionality is experienced differently in different contexts, and can dictate how much access you have (to resources, support, etc.) in society (The University of British Columbia, n.d.). In this sense, we cannot ignore "the power inherent in . . . social positions" (Misawa, 2010, p. 26).

Intersectionality

In this video, What is Intersectionality? [1:54] by the National Association of Independent Schools (2018), Professor Kimberlé Crenshaw talks about the study of how overlapping or intersecting social identities relate to systems and structures of discrimination.

Related to positionality, intersectionality acknowledges the complex relationship between social identities, and systems of power and oppression. Given the fluid, relational, and social construction of identities, intersectional paradigms recognize that every person has multiple and diverse identities (e.g., race, gender, sexual orientation, socio-economic status, dis/ability, beliefs, and worldview) that combine in unique ways to shape our perspectives, and experiences with oppression and privilege (Ontario Human Rights Commission, 2001). In this context, intersectionality recognizes that oppression does not exist within a vacuum, but rather intersecting oppressions work together in producing injustice (Collins, 2001).

The following graphic entitled "Intersectionality" visually displays how social identities intersect with one another and are wrapped in systems of power. For example, using the imagery of a spirograph, Duckworth (2020) colour-codes various social identities including race, ethnicity, gender identity, class, language, religion, ability, sexuality, mental health, age, education, and body size.

Social Identities, Privilege and Oppression

Critical social psychology describes identity as a social construction that is learned through interactions with others and the world, and that has a strong impact on who we become (Allen & Rosatto, as cited in Shah, 2018). Social privilege exists on the basis of complex and intersecting social identities, such as race, gender, ability, class, faith/religion, age and sexuality and the relative distance of these identities to dominant identities and power (Black & Stone, as cited in Shah, 2018).

Wheel of Power/Privilege

Sylvia Duckworth's "wheel of power/privilege" is another visual representation of how power, privilege, and social identities intersect. The graphic below uses the imagery of a wheel, sectioned off by the following social identities and respective categories:

Citizenship: citizen, documented, undocumented

Skin colour: white, different shades, dark

Formal education: post-secondary, high school, elementary

Ability: able-bodied, some disability, significant disability

Sexuality: heterosexual; gay men; lesbian, bi, pan, asexual

Neurodiversity: neurotypical, neuroatypical, significant neurodivergence

Mental health: robust, mostly stable, vulnerable

Body size: slim, average, large

Housing: owns property, sheltered/renting, homeless

Wealth: rich, middle class, poor

Language: English, Learned English, non-English monolingual

Gender: cisgender man; cisgender woman; trans, intersex, nonbinary

In this topic, we hope you learned about yourself, your salient social identities, and how they interact with the systems of power and oppression in our society. To conclude, we invite you to think about your social location and the intersecting identities which shape your interactions within the higher education system. How are these similar and different to your colleagues, students, and administrators? How has academia epistemically favoured scholarship and ways of knowing of those with identities closer to the centre of power? Which social identities do the systems of power historically (and currently) serve?

Referring back to the identities in the Wheel of Power/Privilege think about how you define yourself, and where your salient social identities are located on the wheel. Get curious about:

How close or far away from the centre are you?

How does your level of power shift as you place yourself in different identity categories?

Thinking about your institution, where do students, staff, administrators, and/or faculty reside?

You are invited to record your reflection in the way that works best for you, which may include writing, drawing, creating an audio or video file, mind map or any other method that will allow you to document your ideas and refine them at the end of this module.

Alternatively, a text-based note-taking space is provided below. Any notes you take here remain entirely confidential and visible only to you. Use this space as you wish to keep track of your thoughts, learning, and activity responses. Download a text copy of your notes before moving on to the next page of the module to ensure you don't lose any of your work!

References

Collins, P. H. (2001). Black feminist thought: Knowledge, consciousness, and the politics of empowerment. New York: Routledge.

Duckworth, S. (2020, Aug 19). Intersectionality [Infographic]. Flickr. https://flic.kr/p/2jy46K4.

Duckworth, S. (2020, Oct 18). Wheel of power/privilege [Infographic]. Flickr. https://flic.kr/p/2jWxeGG. CC BY-NC-ND 2.0 .

Misawa, M. (2010). Queer race pedagogy for educators in higher education: Dealing with power dynamics and positionality of LGBTQ students of color. International Journal of Critical Pedagogy, 3(1), 26-35. http://libjournal.uncg.edu/ijcp/article/view/68

National Association of Independent Schools (NAIS). (2018, Jun 22). Kimberlé Crenshaw: What is intersectionality? [Video]. YouTube. https://youtu.be/ViDtnfQ9FHc

Ontario Human Rights Commission. (2001). An introduction to the intersectional approach. http://www.ohrc.on.ca/en/intersectional-approach-discrimination-addressing-multiple-grounds-human-rights-claims/introduction-intersectional-approach

Shah, V. (2018). Leadership for social justice through the lens of self-identified, racially and other-privileged leaders. Journal of Global Citizenship & Equity Education, 6(1). https://journals.sfu.ca/jgcee/index.php/jgcee/article/view/168/399

The University of British Columbia. (n.d.). Positionality & Intersectionality. https://indigenousinitiatives.ctlt.ubc.ca/classroom-climate/positionality-and-intersectionality/

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Universal Design for Learning (UDL) for Inclusion, Diversity, Equity, and Accessibility (IDEA)

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Now that you have spent some time reflecting on equity, diversity, and inclusion, let's dive a bit deeper into how our social identities, positionality, and privilege(s) intersect. Positionality refers to the personal values, views, and location in time and space that influence how one engages with and understands the world.

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The concept of intersectionality describes the ways in which systems of inequality based on gender, race, ethnicity, sexual orientation, gender identity, disability, class and other forms of discrimination "intersect" to create unique dynamics and effects. For example, when a Muslim woman wearing the Hijab is being discriminated, it would be impossible to dissociate her female* from her Muslim identity and to isolate the dimension(s) causing her discrimination.

All forms of inequality are mutually reinforcing and must therefore be analysed and addressed simultaneously to prevent one form of inequality from reinforcing another. For example, tackling the gender pay gap alone - without including other dimensions such as race, socio-economic status and immigration status - will likely reinforce inequalities among women.

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intersectionality 101, what is intersectionality, about CIJ

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2. The 4 Agreements of Courageous Conversations video (5:24)

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2. The 4 Agreements of Courageous Conversations video (5:24)

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The Four Agreements of Courageous Conversations

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3. What is Intersectionality Video (54 secs)

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3. What is Intersectionality Video (54 secs)

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4. Cuyahoga Arts & Culture (CAC) Four Levels of Racism

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4. Cuyahoga Arts & Culture (CAC) Four Levels of Racism

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Many Americans maintain that racism is dead. Those who support this claim of a post-racial society offer some compelling examples. The most often cited "indisputable proof" of our progress is the election of Barack Obama, the first President of color.

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Racial Equity Tools Glossary

Words and their multiple uses reflect the tremendous diversity that characterizes our society. Indeed, universally agreed upon language on issues relating to racism is nonexistent. We discovered that even the most frequently used words in any discussion on race can easily cause confusion, which leads to controversy and hostility. It is essential to achieve some degree of shared understanding, particularly when using the most common terms. In this way, the quality of dialogue and discourse on race can be enhanced.

Language can be used deliberately to engage and support community anti-racism coalitions and initiatives, or to inflame and divide them. Discussing definitions can engage and support coalitions. However, it is important for groups to decide the extent to which they must have consensus and where it is okay for people to disagree. It is also helpful to keep in mind that the words people use to discuss power, privilege, racism and oppression hold different meanings for different people. For instance, people at different stages of developing an analysis tend to attach different meanings to words like discrimination, privilege and institutional racism. Furthermore, when people are talking about privilege or racism, the words they use often come with emotions and assumptions that are not spoken.

Many of the terms in this glossary have evolved over time. For example, given the changing demographic trends in the United States, the word "minority" no longer accurately reflects the four primary racial/ethnic groups. The terms "emerging majority" and "people of color" have become popular substitutes. Also, the terms used to refer to members of each community of color have changed over time. Whether to use the terms African American or Black, Hispanic American, Latinx or Latino, Native American or American Indian, and Pacific Islander or Asian American depends on a variety of conditions, including your intended audiences' geographic location, age, generation, and, sometimes, political orientation.

SOURCE: Project Change's "The Power of Words." Originally produced for Project Change Lessons Learned II, also included in A Community Builder's Toolkit - both produced by Project Change and The Center for Assessment and Policy Development with some modification by RacialEquityTools.org.

The main source for each definition is noted with its term below. Some definitions are paraphrased or updated. If you plan to use a couple of the terms in your materials, we encourage you to keep the SOURCE citation(s) that we have listed for them.

You can download a PDF version of this glossary . Please feel free to share the RET Glossary PDF or post a link on your site. We request that you use the following citation: Racial Equity Tools Glossary, MP Associates, Center for Assessment and Policy Development, and World Trust Educational Services, July 2022.

For guidance on evaluation terms in particular, see .

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Words and their multiple uses reflect the tremendous diversity that characterizes our society. Indeed, universally agreed upon language on issues relating to racism is nonexistent. In this way, the quality of dialogue and discourse on race can be enhanced.

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7. Survey Shows Substantial Racism in Nursing (Infographic)

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7. Survey Shows Substantial Racism in Nursing (Infographic)

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National Nursing Survey Understanding Racism in nursing Infographic

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8. History of nursing profession in ancient Egyptian Society

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8. History of nursing profession in ancient Egyptian Society

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9. Nursing and Caring: An Histroical Overview from Ancient Greek Tradition to Modern Times

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9. Nursing and Caring: An Histroical Overview from Ancient Greek Tradition to Modern Times

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and how nurses are seen within the healthcare field.

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Before COVID-19 was even a blip on the horizon, the World Health Organization had declared 2020 the Year of the Nurse and Midwife. This year was chosen because 2020 marks 200 years since the birth of the so-called Mother of Modern Nursing, Florence Nightingale.

But Nightingale is a problematic figure for nursing. There is little doubt of her impact; her innovations in practice and education have contributed to what we now know as the profession of nursing signified by the RN: the registered nurse. Yet, a focus on Nightingale has often obscured or elided tensions within the history of nursing. These are tensions that run along race, class, and gender lines because modern professional nursing in the Nightingale tradition was deliberately developed as a profession for white, middle class women. That history continues to impact who is able to become a nurse today, and how nurses are seen within the healthcare field.

It also impacts how nurses are seen in the history of health care. To focus only on Florence, or to claim her as the most important nurse of all time, hides the contribution of other types of nurses, and nursing care, and it reinforces the white, Anglocentric view of what it means to be a nurse. To be uncritical of her is to reify the colonizing and biopolitical hegemonies of white, western medicine. This is a history, and a discourse, that requires deconstruction.

2020 is also the year that will be remembered for a once-in-a-century event, the COVID-19 pandemic. Many people are drawing historical parallels between this pandemic and the Spanish Flu pandemic of 1918. For once, the history of medicine is front and center in the public discourse as historians write and speak about lessons that could have been learned but were lost because of the unwillingness of our government and policy to engage with history. To some, it may seem that history is irrelevant to the current situation because the science is so different, technology more advanced, the virus newer and more cunning. Historians, of course, understand that the point of history is not to cure a virus or create a vaccine, but to document the policy failures and successes, to make comparisons across the globe, and to bear witness to the experience of those who live and die through such events.

In the current situation, nurses are everywhere, all over our TV screens, heroes in scrubs, warriors on the front line, risking their own lives to take care of others. For most people who survive the virus, it will be the nursing care they remember. That's why nursing is continually voted the most trusted profession. And yet, nursing care is bundled into the cost of the room, as though nurses are a piece of the furniture. How will history remember them, if it even remembers them at all?

The same dynamics are playing out in the flurry of academic activity around the history of pandemics. As historians of medicine strive to make their voices heard in the media today, to make claims to expertise and authority about the history of public health, too often the history of nurses is being obscured. Public health in particular was historically always the domain of the nurse, and not simply at the behest of doctors and medicine. Nurses had ideas of their own, established clinics of their own, walked the streets and climbed the rooftops day and night to provide care to people who could not afford hospitals, who couldn't be cured, who were too small or unimportant for the doctor to notice. Yet, we are not seeing them in the history work that's making the rounds on Twitter and Facebook and in the Zoom workshops and webinars springing up, especially in relation to the history of pandemics. These events focus on the "heroic" technologies of diagnosis and cure, usually by white male physicians. Very rarely do they consider the everyday work of nurses without whom many more millions would have died. Too often, I see an advertisement for an event that bears the face of the nurse, only to discover it is not about nursing or nurses at all, or that one speaker out of 20 is a nurse or a historian of nurses.

As a historian of nursing, you get used to this erasure. You get used to the photos that historians of medicine use in their conference presentations or on their book covers with the name of the doctor supported by the six nameless nurses in the background. You get used to people claiming heroic innovations that were enacted by, you guessed it, nurses. You get used to publishers wondering if your book would be of interest to anyone except nurses. This is not just a problem of the history of medicine, it is a problem of patriarchy, where the work of women (because nurses have been mostly women) is not valued. Caring work is considered essential, yet somehow also already natural and, therefore, not worth paying for, as Susan Reverby has so carefully documented.

What has changed in the 33 years since Reverby published her call to arms for nurses and historians? There is now an abundance of literature about the history of nurses, both modern and traditional, American and global. You could (and some of us do) build an entire semester's curriculum using only sources about the history of nurses. Much of this work has focused on the actions of white women, as nurse historians seek to write nurses back into the history of medicine. That worthy work has made an impact on nurses and historians of health care who seek to explore the intersection of women and health, but it needs to do more. It needs to expand to include the work of minority women, traditional healers, and health care providers who exist in the liminal spaces.

As we see the central role that nurses provide in the midst of a crisis, the desperate demand for their work and care, we also see a society that is willing to pay them less and send them to work with garbage bags and homemade masks as equipment. To understand how this came about, and how we can change it for the future, we need the history of nursing in all its tensions, complexity, and richness to be front and center in our discourse today.

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Beyond Florence: Valuing Nurses in the History of Health Care

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Before COVID-19 was even a blip on the horizon, the World Health Organization had declared 2020 the Year of the Nurse and Midwife. This year was chosen because 2020 marks 200 years since the birth of the so-called Mother of Modern Nursing, Florence Nightingale. But Nightingale is a problematic figure for nursing.

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11. The Racist Lady with the Lamp: Reckoning with the FULL story of Florence Nightingale 

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11. The Racist Lady with the Lamp: Reckoning with the FULL story of Florence Nightingale 

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Tags: Florence Nightingale, nurses, Nursing, Racism By Natalie Stake-Doucet * Nursing historiography is centered on whiteness. Even worse, nursing history revolves largely around a single white nurse: Florence Nightingale. This, unfortunately, doesn't mean nurses understand who Nightingale was.

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"Make the impact of nurses of color more widely known".

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Started by nurses, the Nurses You Should Know Project is a collaborative campaign designed to raise awareness to the contributions of nurses of color in the nursing profession and healthcare at large.

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14. Revisiting Nurse Eunice Rivers: Tuskegee Syphilis Study

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14. Revisiting Nurse Eunice Rivers: Tuskegee Syphilis Study

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The Tuskegee syphilis study's most enduring figure is also one of its most intriguing. Nurse Eunice Rivers was instrumental to the study for both procuring its members and then keeping them involved in it. Straddling as she did the professional medical world and the world of the study's subjects, she was the ideal link between the disparate spheres. ¹ Over the years, historians who have studied Rivers have found her to be a complex character: a black woman who betrayed her race even as she sought to improve the black subjects' well-being; a nurse who betrayed her profession by dooming those she was charged with caring for. Through modern eyes, she becomes more victim than betrayer: a victim of her gender, powerless to speak up in a man's world, or a victim of race herself, powerless in a world controlled by whites. ² Susan Smith, in "Neither Victim Nor Villain," analyzes the Tuskegee study from the perspective of Rivers as a black professional, in the historical context of her gender and race. ³ Another, equally compelling way to look at Rivers is also within a historical context, again as a medical professional, but this time as one attempting to practice that profession during an economically devastated and racially repressive period of American history. The poverty and unemployment prevalent in the rural South of the 1920s and 1930s is the background against which Rivers ought to be evaluated. And although social conditions don't provide excuses for her involvement in the infamous study, they do offer a context in which to try to make sense of her participation.

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The economic boom before the crash of 1929 didn't skip the South, but its effects there were much different than in other parts of the country. By 1920, for the first time in United States history, most Americans lived in cities, and by 1940 an additional 6 million farmers had left the fields for urban areas, among them cotton growers from the South. ⁴ For rural America, then, the boom before the bust meant a population drain, and in the decade following World War I the South was the most rural region in the country. ⁵ As wartime demand for agricultural products (chiefly cotton) gave way after Armistice Day to material surpluses and overfarmed land, farmers migrated in droves to urban centers. Left behind were those who either could not or would not follow suit. Yet, David Kennedy notes, "the urbanization of early twentieth-century America can be exaggerated. More than one in five working Americans still toiled on the land in the 1920s." At the same time, "a stubborn agricultural depression, the product of war and technological change, badly exacerbated the problems of the countryside." In 1930 four-fifths of all blacks remained in the South. ⁶ President Herbert Hoover decided to address the social problems of the time by gathering the brightest minds in the country (a month before the market crash of October 29, 1929) and asking them to amass nationwide data and analysis that would be, according to Hoover, "the basis for the formulation of large national policies looking to the next phase in the nation's development." ⁷ The report was delivered in 1933: the exhaustive Recent Social Trends, which provided data on everything from the nation's mineral resources to the impact of new technology on work and home life. Writes Kennedy, "From its turgid prose and endless tables emerged a vivid portrait of a people in the throes of sweeping social, economic, and political change, even before they were engulfed by the still more wrenching changes of the Depression era." ⁸ That turgid prose also revealed a stark conclusion: If residents of the rural South were suffering during that era, black residents were suffering significantly worse. Earlier immigration restrictions (via literacy tests, for example) culminated in a 1921 quota law, followed by an even more stringent one in 1924 and then another in 1929. ⁹ The resulting reduced immigrant workforce created employment opportunities for blacks in towns and cities, furthering emptying rural farms of tenant farmers and sharecroppers; a devastating boll weevil infestation in Southeast cotton fields spurred even more relocation as crops failed. ¹⁰ Those who stayed in the countryside lived in deplorable conditions. By as late as 1940, homes for both black and white tenant farmers were valued at around $250. Few houses had running water; fewer still had flush toilets. ¹¹ Black farmers also faced a credit system that was particularly unfavorable to them. The usurious interest rates they were charged (15 percent to 35 percent) drastically ate into already meager profits. "This crop mortgage system is weak to begin with and its abuses make it even more burdensome," Recent Social Trends reported. "With these handicaps the returns from farming are small... After this small product has been divided between tenant, the landlord and the furnisher of credit, the shares are inadequate to support a good standard of living." ¹² It was in this bleak social and economic landscape that Rivers found herself when she was starting her career. And if she hadn't noticed it from the confines of the nursing program at the Tuskegee Institute, she witnessed it firsthand after her 1922 graduation in her first job, with the Movable School. Tuskegee Institute founder Booker T. Washington wanted to teach agricultural techniques to black farmers in the last decade of the 19th century. That idea led to the establishment of an agricultural extension department at Tuskegee and ultimately the Movable School, ¹³ so named because it brought a learning center to people (first by a mule-drawn wagon and later via truck). The original "Farmers' College on Wheels" initially educated farmers on new technology and methods to help improve crop and livestock yields. In 1918, federal funding allowed the hiring of home economics instructors, who taught women canning, cooking, and cleaning, ¹⁴ and later public health professionals came on board to teach basic hygiene and sanitation skills. ¹⁵ In 1923, Rivers joined the school as a public health nurse. In addition to basic hygiene, she taught women and midwives safe birthing methods, childcare, and how to tend to the sick, and provided men information on "social hygiene," euphemism for sexually transmitted diseases. ¹⁶ The Movable School ventured to the farthest rural corners of Alabama, including Macon County, the pool from which prospective subjects for the Tuskegee study would be drawn. For Rivers, the Movable School was more than just an opportunity to advance the Tuskegee Institute's philosophy of service to the indigent; it was a job at a time when jobs were scarce, and it was a good one at that. Landing it was an achievement in itself. Black nurses had fewer employment opportunities than white nurses did, and Southern black nurses lucky enough to find work were paid lower salaries for performing the same duties as their white counterparts. In Alabama, for example, white nurses were paid $110 a month by the board of health, while black nurses received $65. ¹⁷ The openly racist attitudes of even those in the profession compounded the economic inequalities. Darlene Clark Hine writes of Margaret Bruesche, a white nursing teacher in Fairfield, Alabama, who felt that "the negro woman has no place as a graduate nurse." They weren't smart or well educated, "they are not conscientious and their sense of responsibility is very weak." (At least Bruesche was ostensibly assessing professional skills. A white nursing superintendent at Atlanta's Grady Hospital at the time felt black nurses hadn't "any morals... They are such liars...and will cut up each other's clothes for spite.") ¹⁸ Rivers remained with the Movable School for nine years, until the Depression forced financial cutbacks that led to the elimination of her position, leaving her to choose between unemployment and a night nursing supervisor position at the John A. Andrew Memorial Hospital at the Tuskegee Institute. She chose the latter. She hated working the night shift, and less than a year later, as she was preparing to migrate north herself, she heard about a job with the United States Public Health Service, working on a study of the effects of untreated syphilis on black men. ¹⁹ It was an assistant's position, paying a then-attractive $1,800 a year. ²⁰ Rivers's years with the Movable School in and around Macon County, and her concurrent work for the Bureau of Vital Statistics for the Alabama Health Department compiling birth and death records in the same area, were on-the-job preparation for the Tuskegee position. Her experience and performance were impressive enough that Dr. Eugene Dibble, medical director of the Tuskegee Institute and head of the Andrew Hospital, recommended Rivers, who had been one of the institute's star nursing school pupils, for the opening. She was hired for the study in 1932 to monitor the participation of its black subjects. ²¹ With 21st-century eyes it might be difficult to see how a black woman would be willing to participate in something called "The Tuskegee Study of Untreated Syphilis in the Negro Male." But in light of the prevailing economic conditions in the rural South early in the previous century, it is not so hard to discern reasons why. Syphilis was rampant and posed a serious health threat, and treatments available then were harsh. ("I saw so many reactions with these medications," Rivers said in an interview. ²²) The natural progression of the disease was to be studied in hopes of determining better treatments. ²³ By taking the job with the U.S. Public Health Service, Rivers would be working to help the people she knew to be in desperate need of medical attention. Also, in the beginning decades of the 1900s, it was presumed that the course of the disease progressed differently through blacks than it did through whites-the Tuskegee study would complement the Oslo study of untreated syphilis in whites. ²⁴ "This is the way I saw it: that they were studying the Negro just like they were studying the white man, see, making a comparison," Rivers said later. ²⁵ Yet given the scarcity of good jobs for black women, in the rural South in particular, a perhaps more compelling reason for Rivers to join the study is simply that it offered employment-and a chance to get off the odious night shift. ("I was so glad to go off night duty that I would have done anything," Rivers said. ²⁶) That the position was one in the career for which Rivers had trained was a bonus. Nursing positions were not easy to come by, and the Depression was forcing state public health departments to cut funds. ²⁷ The unemployment rate for the country was approaching 25 percent. ²⁸ Rivers was an ideal candidate for the job. She had been an exemplary student at Tuskegee. She'd done administrative work for the Bureau of Vital Statistics, and nursing school had trained her to examine patients. The Movable School had taught her public outreach and the interpersonal skills of a public health nurse; her personality and tact were remarkable. ²⁹ In fact, Dr. Dibble cited her effectiveness as a public health worker when he suggested her for the Tuskegee position. ³⁰ The relationships she established with the people in Macon County from her Movable School days would be the key to her success in the Tuskegee job. Other syphilis studies were being conducted at the time, and a lack of patient compliance with treatment protocols was an ongoing, pervasive challenge. A Birmingham, Alabama, doctor who had worked with public health syphilis programs noted that failing to keep up with treatment until cure was an issue for both blacks and whites, and that developing a way to keep patients compliant would be essential to any program's success. ³¹ As it turned out, Rivers excelled at making sure that patients enrolled in the study stuck with it. The study was originally designed to last six to eight months, but of course it went on far longer, and by the time the decision was made to leave the termination date open-ended, Rivers was a firmly entrenched Tuskegee team member. After all, notes Susan Smith, "Rivers considered her participation in the study merely a continuation of her previous public health work." ³² Over the course of the study she had become more than just an assistant; she was, if not in title, the de facto chief liaison between the doctors and the subjects. Dr. Raymond Vonderlehr, director of the Public Health Service's venereal disease division and the head of the study from its inception till 1943, acknowledged Rivers's skills in ensuring the ongoing compliance of the subjects. ³³

*

If Rivers's complicity in withholding treatment in the original study can be understood within the economic and employment contexts of the time, can it also explain why a caring, dedicated nurse would continue to risk the lives of her patients-patients she had known and followed for 15 years-after an accepted treatment for syphilis became available, in the mid-1940s? Yes, but this time Rivers needn't be regarded as someone lucky enough to have a job but rather as a dedicated Tuskegee team member. If she was an entrenched member of the Tuskegee team when the decision was made to continue the study indefinitely, by the time penicillin was widely available she would have been a full-fledged "company woman." Others in the study came and went over the years, but Rivers steadfastly remained. (She was replaced by Elizabeth Kennebrew in 1965 but continued to help Public Health Service physicians when they were in town, and remained in contact with the men. ³⁴) Rivers was a loyal employee who identified more with the researchers-the company-than she did with the subjects. Born and raised in rural Georgia, ³⁵ she may have come from the subjects' world, but even at the beginning of the study she didn't live in it anymore. Ten years out of nursing school, she was working steadily, both for Tuskegee and in her midwife-training capacity. ³⁶ She was a working professional. Smith refers to "Rivers and other black professionals," and suggests that this professionalism may have "blinded them to the high price paid by poor, rural black men in the study." ³⁷ To the scientific assistant part of Rivers, the poor, rural black men were subjects; to the nurse part of her they were patients. But more important, they were her job. She was working for an organization whose purpose was to gather data on untreated syphilis in black men; thus, it would have been more surprising if treatment had been provided. As some journalists realized at the time, given the study's design, withholding penicillin was a foregone conclusion. Penicillin was withheld because all treatment was withheld. ³⁸ Darlene Clark Hine suggests that "[years] of conditioning and living in the South made it virtually impossible for Rivers to have rebelled against a white, male government doctor, the ultimate authority figure in her world." ³⁹ Looking at Rivers as a loyal employee accounts for her subservience to the white government-official doctors in charge in a different way: They were her bosses, and as a good employee she did what the bosses told her to do. Telling moments from two interviews with Rivers suggest she strongly identified with the Tuskegee study team. She rarely spoke of her role in the scandal, ⁴⁰ and so publicly expressed few regrets. However, in a 1977 conversation with Helen Dibble and Daniel Williams, she allowed one: that the results of the study's labor may have been lost. "[T]his was the thing that was so disturbing to me was that somehow all of the records of this study and the health department have been destroyed," she told them. ⁴¹ Another moment came in an interview with James Jones several years after a $10 million class-action lawsuit against the U.S. government was settled with the living participants of the study, in 1974. ⁴² Jones and Rivers were driving through Macon County when Rivers saw a former study participant in a field and went out to say hello. When the man asked her why she had stopped coming by to see him, she told him, "You don't get the money and Nurse Rivers too." ⁴³

*

Considering Rivers in the specific socioeconomic context in which she lived is one more way to make sense of her ongoing participation in what is now known as a deadly racist medical experiment perpetrated against Rivers's own friends and patients. By first seeing her as fortunate to have secured a position with the study and then as a loyal team member later on, she escapes the harsher accusations of race traitor and coward; more important, it is consistent with her remaining in history the dedicated, caring nurse she professed to be. "Really and truly," said Nurse Rivers, "when we were working with those people...that was the joy of my life." ⁴⁴ Today she might simply be called a cog in the machine, but half a century ago she was someone lucky to be working in her chosen profession when nearly a quarter of the country was not working at all, someone who did not have the luxury of resigning in protest.

1. James H. Jones, Bad Blood: The Tuskegee Syphilis Experiment-A Tragedy of Race and Medicine (New York: The Free Press, 1981), p. 6.

2. Susan M. Reverby, Examining Tuskegee: The Infamous Syphilis Study and Its Legacy (Chapel Hill: The University of North Carolina Press, 2009), p. 168.

3. Susan L. Smith, "Neither Victim Nor Villain: Eunice Rivers and Public Health Work," Tuskegee's Truths, ed. Susan M. Reverby (Chapel Hill: The University of North Carolina Press), p. 349.

4. David M. Kennedy, Freedom from Fear: Part I: The American People in the Great Depression (New York: Oxford University Press, 1999), p. 16.

5. Ibid., p. 18.

6. Ibid., p. 16-17.

7. Ibid., p. 11-12.

8. Ibid., p. 12.

9. Recent Social Trends in the United States: Report of the President's Research Committee on Social Trends (New York: McGraw-Hill Book Company, Inc., 1933), p. 557.

10. Ibid., p. 566.

11. Wayne Flynt, "Poverty in Alabama" (Encyclopedia of Alabama, http:encyclopediaoflabama.org, November 2007).

12. Recent Social Trends, p. 570.

13. Felix James, "The Tuskegee Institute Movable School, 1906-1923," Agricultural History, July 1971: Vol.45, No. 3, p. 202.

14. Ibid., p. 206.

15. Ibid., p. 208.

16. Reverby, Examining Tuskegee, p. 170.

17. Darlene Clark Hine, Black Women in White: Racial Conflict and Cooperation in the Nursing Profession 1890-1950 (Bloomington: Indiana University Press, 1989), p. 92.

18. Ibid., p. 101.

19. Reverby, Examining Tuskegee, p. 170.

20. Jones, Bad Blood, p. 102.

21. Ibid., p. 6.

22. Laurie interview; Eunice Rivers, Stanley H. Schuman, Lloyd Simpson, and Sidney Olansky, "The Twenty Years of Follow-up Experience in a Long-Range Medical Study, Public Health Reports 68 (1953): 394, cited in Jones, Bad Blood, p. 163.

23. "The U.S. Public Health Service Syphilis Study at Tuskegee" (Centers for Disease Control and Prevention, www.cdc.gov/tuskegee).

24. Smith, "Neither Victim Nor Villain," p. 354.

25. Laurie interview, p. 167.

26. Ibid., p. 111.

27. Ibid.

28. Robert VanGiezen, Albert E. Schwenk, "Compensation from Before World War I Through the Great Depression," Compensation and Working Conditions, Fall 2001 (Bureau of Labor Statistics, www.bls.gov/opub/cwc/cm20030124ar03p1.htm, posted Jan. 30, 2003).

29. Clark Hine, Black Women in White, p. 155.

30. Jones, Bad Blood, p. 111.

31. Ibid., p. 46.

32. Smith, "Neither Victim Nor Villain," p. 358.

33. Jones, Bad Blood, p. 116.

34. Reverby, Examining Tuskegee, p. 172.

35. Ibid., p. 169.

36. Ibid., p. 172.

37. Smith, "Neither Victim Nor Villain," p. 360.

38. Jones, Bad Blood, p. 9.

39. Clark Hine, Black Women in White, p. 156.

40. Reverby, Examining Tuskegee, p. 168.

41. Helen Dibble, Daniel Williams, "An Interview with Nurse Rivers," Tuskegee's Truths, ed. Reverby, p. 327.

42. "The U.S. Public Health Service Syphilis Study at Tuskegee: The Tuskegee Timeline" (Centers for Disease Control and Prevention, www.cdc.gov/tuskegee).

43. James H. Jones to Susan M. Reverby, Personal Communication, July 7, 2004, cited in Reverby, Examining Tuskegee, p. 183.

44. Jones, Bad Blood, p. 161.

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The Tuskegee syphilis study's most enduring figure is also one of its most intriguing. Nurse Eunice Rivers was instrumental to the study for both procuring its members and then keeping them involved in it. Straddling as she did the professional medical world and the world of the study's subjects, she was the ideal link between the disparate spheres.

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On June 11, 2022, the ANA Membership Assembly, the governing and official voting body of ANA, took historic action to begin a journey of racial reckoning by unanimously voting 'yes' to adopt the ANA Racial Reckoning Statement.

This statement is a meaningful first step for the association to acknowledge its own past actions that have negatively impacted nurses of color and perpetuated systemic racism.

For more information, please read the frequently asked questions.
Download PDF version
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Racism: Assaults on the human spirit in the form of actions, biases, prejudices, and an ideology of superiority based on race that persistently cause moral suffering and physical harm of individuals and perpetuate systemic injustices and inequities.
(National Commission to Address Racism in Nursing, 2021)
"If I were to replace my face with a white person's face, where would my career be?"
Opening
This is a journey.
Throughout our history, the American Nurses Association (ANA) has sought to lead nursing into the future. Through acts of omission, when we failed to act, and commission, when ANA's actions negatively impacted nurses of color, we have caused harm and perpetuated systemic racism. This statement serves as a starting point for a journey during which we seek to acknowledge past actions that continue to impact the profession today and as a starting point of a new journey toward the future.

ANA begins this journey in conjunction with the efforts undertaken by the National Commission to Address Racism in Nursing (the Commission). This statement focuses on ANA's own actions, while the Commission seeks to address racism in nursing within the broader profession. We recognize that as a leader, ANA holds accountabilities at both the organizational and the broader professional level. Through both efforts, we are striving for a more inclusive, diverse, and equitable professional organization and a nursing profession that meets the needs of all people.

Our intention with this statement is to publicly identify and acknowledge our past actions while addressing the harms that continue today. The section on ANA Reckoning is not meant to be a complete listing of all ANA actions that have caused harm. Historical exclusions of and transgressions against Black nurses will be discussed in this document. This harm has undoubtedly extended to all nurses of color. In addition, there is much debate about labels and terms to identify racialized minorities. We have chosen to use the term "nurses of color" to reflect all nurses representing race and ethnic groups. It is our intention to be fully inclusive in the use of this language.

In the end, it is our actions that will truly reflect the sincerity of this apology and serve as the underpinning for forgiveness. For it is forgiveness that we seek - forgiveness from nurses of color, the nursing profession and the communities that have been harmed by our actions. We fervently hope that this statement, its subsequent work and the efforts of the Commission will contribute to healing - individual healing for nurses, reconciliation with the ethnic-minority nurse associations and healing of the profession. ANA wants this statement to reflect genuine reconciliation and acknowledgment and hopes that it is a step toward forgiveness. Ultimately, we seek to contribute to the healing of nursing.

ANA Reckoning

There is much that can be said about ANA's history and failure to include and represent the views and needs of nurses of color. The examples below are not to be considered as a complete reckoning of ANA's past, but they are representative of times and actions when ANA failed.

To begin, we must acknowledge that from 1916 until 1964, ANA purposefully, systemically and systematically excluded Black nurses. ANA's predecessor organization, the Nurses' Associated Alumnae of the United States and Canada, was open to alumnae associations of schools of nursing, including Black hospitals and nurse training schools (Hine, 1989). The Nurses' Associated Alumnae became the American Nurses Association, and in 1916, the membership rules shifted away from an alumnae-based membership to that of a state- and district-based membership. This resulted in Black nurses being denied membership in some state nurses associations. Despite significant advocacy and pressure from the National Association of Colored Graduate Nurses (NACGN), this discrimination persisted. In 1946, the ANA House of Delegates voted to adopt a statement that urged the "removal, as rapidly as possible, of barriers that prevent the full employment and professional development of nurses belonging to minority racial groups" (Carnegie, 1991, p. 76). And in 1948, the ANA House of Delegates established an "Individual Membership Category" that was open to all nurses who were not accepted through a state or district association. However, it was not until 1964 that a final district in Louisiana dropped its discriminatory rule for membership (Carnegie, 1991). This timeline reflects the failure of ANA leaders to aggressively pursue changes in its discriminatory membership rules and allow for full membership regardless of race. While membership within ANA was hard fought by NACGN, the full inclusion of Black nurses within ANA leadership and decision-making remains unrealized and elusive for all nurses of color.

One representative incident from 1939 involved Estelle Massey Riddle Osborne, president of NACGN from 1934-1939. In 1939, President Osborne was invited by ANA President Julia C. Stimson to meet with ANA's Advisory Council to discuss the status of Black nurses in the profession. The site of the meeting was the St. Charles Hotel in New Orleans, where Black guests were required to use the service entrance and freight elevator. President Osborne called on ANA and President Stimson to adamantly protest this discrimination. Instead of protesting the discriminatory policy, President Stimson offered to enter the hotel with President Osborne through the service entrance. In the end, President Osborne decided against attending and ANA failed to step into a space of advocacy and support (Hine, 1989).

President Osborne was the first Black nurse to earn a master's degree in the U.S. and became the first Black nurse elected to the ANA board in 1948. However, after her four- year term, there were no Black nurses elected to the board again until 1970 (Carnegie, 1991). This lack of representation on the policy level for 22 years concerned many Black nurses, and when it was brought up at ANA's 1972 convention, it was communicated that the only obligation of ANA from the dissolution of NACGN was the awarding of the Mary Mahoney Award.

In 1965, ANA approved a position paper on nursing education that recommended the minimum preparation for "beginning professional nursing practice should be a baccalaureate degree" (ANA, 1976). The stated rationale for this change was the increasing complexity of nursing activities and patient care. One result of ANA taking this position was the disenfranchisement of institutions and schools of nursing that were available to students of color and the exclusion of nurses who graduated from those programs. ANA sought to advance the educational level of nurses without ensuring that all nurses would have the same access to the education necessary to achieve the desired educational level for entry into the profession. There continues to be a need to examine how this policy advances nursing today and to examine strategies for ensuring that educational opportunities are equally available to all students, especially students of color.

In 1970, Dr. Lauranne Sams organized a meeting with 200 Black nurses for the primary purpose of organizing a Black nurse association. The group reported the following concerns (Carnegie, 1991):

1. Concern over the absence of Black nurses in leadership positions at ANA.

2. Limited opportunities for Black nurses to support and shape ANA policies.

3. Persistent tokenism.

4. Limited recognition of Black nurses' contributions to the profession.

5. Lack of significant increases in the number of Black registered nurses.

6. No recognition of achievement with awards (other than the Mary Mahoney Award).

7. Limited appointments of Black nurses to committees and commissions.

In 1973, in her first address to the newly created National Black Nurses Association (NBNA), Dr. Sams considered the question of why a Black Nurses Association was needed:
"No, I am speaking about all the past deficits and discriminatory practice which have continuously disgraced and limited the full potential, the development, the selfhood, and the self determination of Black folk. I am speaking about today, Here and Now."
In telling the history of the formation of the NBNA, the article From Invisibility to Blackness: The Story of the National Black Nurses' Association by Gloria R. Smith notes that there was a desire on the part of the Nurses' Associated Alumnae of the United States and Canada and ANA for Black nurses to be members, but these professional associations granted them few privileges "other than paying dues" (1975, p. 225).

Although by 1964 there were no tangible rules preventing membership for nurses of color, it was evident that exclusionary practices and a failure to represent all nurses remained. Similar to the concerns raised by Black nurses, in 1974, led by Dr. Ildaura Murillo- Rhode, a group of 12 Hispanic nurses who were also members of ANA came together to consider establishing a Hispanic Nurses Caucus within ANA because "ANA was not being responsive to the needs of Hispanic nurses" (National Association of Hispanic Nurses, 2022). Ultimately, this core group and their organizing efforts led to the establishment of the National Association of Hispanic Nurses (NAHN). Today, "NAHN members advocate, educate, volunteer, seek partnerships, and conduct programming in the Latino community to improve outcomes, elevate literacy, heighten education, and influence policy. We also work collaboratively with others to improve health equity and to create a future in which everyone regardless of race or ethnicity has opportunities to be healthy."

ANA recognizes that issues of racism persist today and continue to harm nurses of color. Findings from the Commission's 2021 national survey on racism in nursing (n = 5,600) noted that racist acts are principally perpetrated by colleagues and those in positions of power. Over half of nurses surveyed (63%) said they had personally experienced an act of racism in the workplace with the transgressors being either a peer (66%) or a manager or supervisor (60%). Fifty-six percent of respondents also noted that racism in the workplace has negatively impacted their professional well-being. During listening sessions with nurses of color convened by ANA and the Commission, persistent themes of stereotyping, prejudice, discrimination, exclusion, oppression, tokenism, inequity, and insistence on conformity and assimilation were found (National Commission, 2021). The impact of these experiences is demoralization, exhaustion, spirit murder (murder of the soul), invisible workload, silence, invisibility and self-doubt.
"The power in nursing is primarily held by middle-age to old-age white women who have just recently begun to consider racism in nursing care. There are racist principles that have been carried down through history and never challenged."
(Anonymous Quote, National Commission to Address Racism in Nursing, 2021)
Seeking Forgiveness

As leaders of ANA, we apologize for the named and the unaccounted-for harms. Our past actions have caused irreparable physiological, psychological and socioeconomic harm, not only to nurses of color but to all patients, families and communities that depend on ANA as the national leader of the nursing profession. We failed to live up to the professional values established through the Code of Ethics for Nurses (ANA, 2015) and our social contract that guides the relationship between the nursing profession and society and their reciprocal expectations (ANA, 2010). In addition, as ANA sought to "professionalize" nursing, we failed to support a robust education approach that included the appropriate preparation to care for ALL our patients, especially patients of color.

More specifically, we apologize to all nurses of color. Not only is the profession richer for your having persisted, but the people you cared for and continue to care for today have been better served. ANA failed to uphold your work and support you as you advanced in nursing and worked to improve the profession. Having failed you, ANA also failed in supporting and caring for communities of color and other marginalized people.

We apologize to the ethnic-minority nurse associations that have ably represented the needs of their nurses and communities. Early in the profession's history, there was a stated desire for one association to meet the needs of all nurses. ANA only represented the needs of some nurses and some patients. Nurse leaders of color stepped into the breach. ANA's failure to lead resulted in a fragmentation of the profession that contributed to a fragmentation in nursing care for minoritized communities.

Moving Forward

As important as it is to reconcile ANA's history, our path points toward the future and actions that should be taken as a means of holding ANA accountable, continuing reconciliation to repair the breach and becoming a restored association. Each of the actions below will lead to additional actions and efforts as ANA continues the journey.

Therefore, the ANA Board of Directors will:

Continue to reckon with and apologize for past harms that are made known to ANA.

Engage in direct reconciliation with each of the ethnic-minority nurse associations.

Develop and implement a diversity, equity and inclusion impact analysis that is considered in all policies and positions of the association.

Initiate an oral history project dedicated to amplifying the contributions by nurses of color to ANA and the nursing professions.

Therefore, the American Nurses Association will:

Continue to serve as a partner in and support the National Commission to Address Racism in Nursing as it strives to create antiracist practices and environments.

Advocate for and follow established guidance on the reporting of race and ethnicity in professional journals and publications.

Advocate for appropriate representation and inclusion in textbooks and other educational material.

Actively engage in a program of diversity, equity and inclusion within the association.

Provide transparency into the race and ethnic makeup of the ANA Board of Directors, leadership and staff.

Deliberately work to build diversity within ANA's volunteer and governance structure.

"As nurses we need to unlearn much of what we thought we knew about racism - and get comfortable being uncomfortable about our profession and our own way of being - need to see nursing through a new lens and be open to what we might see versus stating that racism does not exist."Sign up to stay informed Download PDF version
(Anonymous Quote, National Commission to Address Racism in Nursing, 2021)
Conclusion

We, as ANA, are on a journey - a journey of reckoning and reconciliation, forgiveness, and healing. This journey will take some time, but it is one that ANA is fully committed to. We invite others to join us as ANA seeks to strengthen who we are as a professional association and the broader nursing profession through inclusion, diversity and equity as we strive for antiracist nursing practices and environments.

References

American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. American Nurses Association.

American Nurses Association. (2010). Nursing's social policy statement: The essence of the profession. American Nurses Association.

American Nurses Association. (1976). One strong voice: The story of the American Nurses Association. American Nurses Association.

Carnegie, M.E. (1991). The path we tread: Blacks in nursing, 1854-1990. National League for Nursing Press.

Hine, D.C. (1989). Black women in white: Racial conflict and cooperation in the nursing profession 1890-1950. Indiana University Press.

National Association of Hispanic Nurses. (2021). History. https://www.nahnnet.org/history.

National Commission to Address Racism in Nursing. (2021). Defining Racism. final-defining-racism-june-2021.pdf (nursingworld.org).

National Commission to Address Racism in Nursing. (2021). Summary Report: Listening Sessions on Racism in Nursing. final-racism-in-nursing-listening-session-report-june-2021.pdf (nursingworld.org).

National Commission to Address Racism in Nursing. (2022). Survey Shows Substantial Racism in Nursing. (nursingworld.org).

Sams, L. (1973, September). Presidential Address. National Black Nurses Association. Cleveland; Ohio.

Smith, G.R. (1975). From invisibility to blackness: The story of the National Black Nurses Association. Nursing Outlook, 23(4), 225-229.

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On June 11, 2022, the ANA Membership Assembly, the governing and official voting body of ANA, took historic action to begin a journey of racial reckoning by unanimously voting 'yes' to adopt the ANA Racial Reckoning Statement.

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16. Chronic Noncancer Pain Management and Systemic Racism: Time to Move Toward Equal Care Standards

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16. Chronic Noncancer Pain Management and Systemic Racism: Time to Move Toward Equal Care Standards

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Introduction

Although it is widely recognized that the United States has a severe and broad systemic racism problem, recent events have dramatically elevated the issue. Widespread protests in the US and around the world have brought much-deserved attention to the plights of Blacks, Indigenous and People of Color (BIPOC) regarding injustices that they experience on a daily basis. For the sake not only of BIPOC, but communities and societies as a whole, racial injustice can no longer be ignored or minimalized.1

Racism in medicine dates to antiquity. Byrd and Clayton noted that the ancient Greeks viewed all slaves as inherently inferior and less intelligent, and that Aristotle displayed particular prejudice toward Black and Asian people.2 This laid the foundation for White superiority and non-White inferiority espoused by Galen, the 2nd-century Roman physician.3 Views of non-White individuals as "subhuman" persisted in Europe, and were brought to the Americas by Caucasian Western Europeans.2 White superiority and racism were used as a justification for enslaving Africans and Indigenous peoples for the financial gain of White colonizers. Non-White inferiority served as the bedrock of slavery, an ideology that was necessarily maintained by the White elite to continue their exploitation of Black persons. Enslaved Africans were provided with medical care only when financially advantageous to their owners.4 It was assumed by White American physicians that Black patients inherently experienced poor health, and this assumption persisted into at least the late 20th century, perpetuated in part by racial stereotypes, stigma and bias in medical school curricula.2 Even after the Civil War, racism in medicine persisted, with the profession writing off Black individuals as a "syphilis-soaked" and unfit race.5 Well into the 1900s, Black individuals were overutilized in medical demonstrations and risky experimentation,6 with the Tuskegee experiments leaving 500 poverty-stricken Black men with untreated syphilis.7 This long history of unequal treatment has rightfully led to a distrust of the medical community by Black patients.8

The 1965 Civil Rights Act and the creation of Medicare and Medicaid resulted in improved access to health care for Black patients, and limited efforts to improve access to medical education for underrepresented groups were made.9 Regardless, systemic racism in American medicine has persisted, resulting in problems with access, inferior treatment and poorer outcomes for BIPOC patients in every area of health care.10 Since arriving in the United States, Black individuals have had the worst health outcomes of any racial group-not in small part due to stigma, systematic oppression, and lack of access to care.2

Today, implicit bias continues to negatively influence multiple avenues of the care continuum including access and quality of care. Bias also affects patient and provider communication, treatment-related decisions and ultimately contributes to poorer health outcomes and health disparity.11 In addition, studies show systemic racism, including discrimination, inflicts continued trauma, which increases hypervigilance and stress particularly in Black, Latinx, and Indigenous patients. Collectively these factors lead to a greater negative cumulative impact on both physical and mental health. Such impacts are manifest as changes in cardiovascular, metabolic, inflammatory, and psychological responses.12,13

In 2008, the American Medical Association (AMA) issued a formal apology for racism in medicine.14 While this was a symbolic gesture, acknowledgement of wrongful past actions particularly toward Black individuals was a step in a positive direction toward building trust and improving health equity. In 2020, the AMA updated their AMA Manual of Style when classifying race and ethnicity in medical literature. This manual now recommends providing more information on race and ethnicity in research studies and calls for capitalizing Black and White race identifiers to align with the capitalization of other racial and ethnic categories. These changes signal an acknowledgment that race and ethnicity continue to play a role in disparities in medicine.15

Racism in Pain Medicine: A Review of the Literature

As is the case in medicine, broadly, racial and ethnic disparities plague BIPOC patients suffering from pain. Disparities in pain assessment and treatment stem from both the personal nature of pain experiences and provider-related racial bias regarding pain in BIPOC patients, which can lead to undertreatment of pain.16 Further, failure by clinicians to account for the significance of cultural context in patient behavior cues and pain coping skills hampers assessment and treatment decisions.17 Much of the early research demonstrating these disparities pertained to their ability to predict oligoanalgesia in emergency medicine. For example, Todd and colleagues determined that Latinx patients with isolated long-bone fractures presenting to the Emergency Department (ED) were only half as likely as non-Latinx White patients to receive opioid analgesia.18 This finding was particularly poignant given the results of a follow-up study published the following year from the same ED, which found no difference in physician ability to assess pain between Latinx and non-Latinx White patients.19 Further, data indicate that Latinx and non-Latinx White patients have the same expectations for analgesia in EDs.20 Another study determined that Black patients with long-bone fractures in the ED were significantly less likely to receive opioids than White patients, and significantly more likely to receive no analgesics whatsoever.21 Perhaps even more distressing are results from a study demonstrating that Black patients were significantly more likely to be denied insurance authorization for ED visits than were White patients.22 On a more general basis, myriad studies have demonstrated that BIPOC patients have historically been less likely to receive opioid analgesia than are White patients across ages and painful conditions.23-33 Unfortunately, recent studies continue to demonstrate that BIPOC patients presenting with painful conditions continue to face disadvantages regarding assessment and treatment in EDs,34-38 with patient perceptions of this disparity serving as a barrier to even seeking emergency care.39 Similarly, a 2018 study of traumatically injured individuals requiring emergency medical services (EMS) transport to hospitals found that significantly fewer Black patients received opioids prehospital compared to other ethnic groups.40 Similar findings were obtained from a more recent study.34 Studies have found that implicit bias among providers affects their clinical judgement, decisions and behavior. Racial and ethnic stereotypes also influence assessments and treatment, especially with high pain intensity self-report among BIPOC patients.41-43 Use of the Implicit Association Test (IAT) in health systems has indicated that implicit bias among clinicians leads to discrimination and unequal care.44 Higher implicit bias among physicians is associated with specific behaviors such as failure to make eye contact with patients, using a condescending tone and pitch, discordant word choices, and more top-down directive communication with BIPOC patients. This negatively influences trust, causes anxiety, and leads to poorer outcomes.45,46

Although the literature on disparities that BIPOC patients with acute painful conditions face in EDs is discouraging, numerous studies support the presence of disparate treatment in all areas of pain medicine, from assessment to treatment. Regarding diagnosis, for example, a VA study determined that Black patients in primary care were significantly less likely to be screened for pain than were White patients.47,48 Further, several studies have indicated that BIPOC patients were less likely to receive advanced diagnostic imaging compared to White patients.49-53 Given these findings, it is not surprising that BIPOC patients' pain is less likely than that of White patients to be treated through rehabilitative approaches such as physical therapy54-59 or addressed surgically.49,60-69

Regarding racial and ethnic disparities in adult acute postoperative pain, McDonald found that White patients received higher dosages of opioids following appendectomies than did BIPOC patients.70 Ng and colleagues found in two 1996 studies that Black and Latinx patients received significantly less opioid analgesia than White patients following open reduction and internal fixation of a limb fracture.48,71 McNeill and colleagues determined that non-White hospital inpatients who had undergone surgeries were less satisfied with their analgesia than were White patients.72 Jimenez and colleagues found that Latinx children undergoing tonsillectomy and adenoidectomy received 30% less opioids than did White children.73 A more recent study of pediatric postoperative pain using case vignettes determined that as pediatricians' pro-White bias increased, they became less likely to express willingness to prescribe to Black patients with an unvarying willingness to prescribe to White patients.74 Similarly, two studies determined that BIPOC women were less likely to receive opioid analgesics postpartum compared to White women.75,76 Again, this is not surprising given the findings that White women were more like to receive neuraxial anesthetics for caesarian sections than were Black and Latinx women.77,78

BIPOC outpatients with chronic noncancer pain in a wide variety of settings have been found less likely to receive opioid analgesia than White patients, with these findings unfortunately having persisted for several decades to the present.79-92 Yet, with so many investigations indicating the difficulty experienced by BIPOC patients regarding access to opioid analgesia, studies suggest that they are generally subjected to even more aggressive risk mitigation procedures by providers. For example, Black patients receiving opioid analgesia were found to be more likely to be subjected to urine drug testing and restricted early refills than White patients,93 with similar findings obtained in a 2013 Veterans' Administration study.94 Not surprisingly, Black chronic pain patients were determined to be more likely to have their long-term opioid therapy discontinued following the detection of illicit drug use than were White patients.95 Additionally, in this day of involuntary opioid tapers among non-aberrant and stable chronic pain patients, multiple studies have demonstrated that Black patients are more likely to have their dosages reduced than are White patients.96,97 These findings are particularly discouraging in light of recent data indicating that prescription pain medication misuse is less common among Black patients than in any other racial and ethnic group studied,98,99 as well as those from a 2018 study that found that prescription opioid abuse was significantly lower among Black and Latinx patients admitted for opioid misuse treatment as compared to admitted White patients.100 Further, recent data determined that deaths from prescription opioids are more common among White individuals misusing than BIPOC misusers.101 Finally, a 2020 study determined that while BIPOC chronic pain patients were less likely than White patients to receive a prescription for opioids, they were more likely to receive a prescription for naloxone, signaling providers' heightened mistrust of BIPOC patients' personal medication management.102 This is consistent with the "racialization" of legitimate opioid use vs prescription and illicit opioid misuse that has been described in the literature.103,104 Collectively, these studies paint a clear picture of BIPOC patients being perceived as less "worthy" of opioid analgesia, at higher risk of aberrancy, and requiring more rigorous risk mitigation - irrespective of the data demonstrating that this represents an egregious false narrative.

Another empirically established cause of BIPOC patients receiving inadequate analgesia compared to White patients is a disparity in pharmacy access. Pharmacies in predominately underrepresented neighborhoods serving BIPOC patients were found in two early studies to be less likely to receive sufficient opioid analgesic supplies compared to those in predominately White neighborhoods.105,106 Further disparity can be identified through a 2017 study determining that generally, areas with more BIPOC residents per capita had significantly fewer pharmacies,107 thereby increasing the challenges that BIPOC patients endure in their efforts to obtain all prescribed medications - including those for pain. This is consistent with the results of earlier studies identifying access issues in heavily underrepresented neighborhoods, which the authors identified as "pharmacy deserts" and "medication deserts".108,109 Additionally, a 2014 study determined that race was a determinant of access to pharmacy services such as discount generic drug programs.110 Thus, BIPOC patients are forced to deal not only with challenges relating to obtaining prescriptions for adequate analgesia but with difficulties in actually being able to fill prescriptions should they obtain them.

Access to pain care based on financial deprivation and/or insurance coverage is another disparity with which BIPOC patients are faced. This is not surprising given that racial/ethnically underrepresented patients have more limited access to health care due to their insurance coverage (or lack thereof), generally.111-115 Studies have determined that BIPOC patients have less access to quality pain care than White patients due to their insurance or inability to afford copays and other out-of-pocket expenses, which tends to result in poorer outcomes.116-121 In addition to economic barriers, literacy and language barriers also present challenges in accessing pain treatment for BIPOC individuals and can lead to miscommunication further eroding trust and influencing treatment decisions.122,123

Numerous studies have demonstrated a strong positive relationship between perceived racial and ethnic discrimination and pain intensity.124-136 This is of particular importance, given the literature indicating that the experience of discrimination predicts inferior physical and mental health outcomes.137-139 Not surprisingly, data also indicate a positive relationship between perceived injustice and pain severity as well as poorer pain outcomes among BIPOC compared to White patients.140-144 Perceptions of racial injustice have been well established as undermining BIPOC patients' trust in the medical establishment in which they are treated,145-149 with this lack of trust potentially compromising pain management efforts and their outcomes. Data suggest that due to perceptions of discrimination, many BIPOC individuals go so far as to delay, avoid seeking, or prematurely discontinue health care.150-153 Again, BIPOC patients' access to adequate medical treatment becomes compromised, potentially resulting in increased morbidity and even mortality.

Moving Toward Equal Care Standards

Society has identified myriad social injustices at the systemic level stemming from inherent bias, discrimination and long-held stereotypes that lead to unequal healthcare, yet the medical community and policymakers have failed to enact substantial measures to right past wrongs. While there are a multitude of discussions regarding unequal access and treatment of BIPOC patients in health research, within health systems and broadly in our communities, change has been slow and perfunctory. Up to this point, we have summarized myriad studies demonstrating the pervasiveness of racially motivated disparities in pain care in the US. However, simply raising awareness of implicit and explicit bias is insufficient; the time for definitive action toward substantial improvements in the racial determinants of pain care is now.

To deconstruct the current system and rebuild it, increasing trust and addressing gaps in access and treatment will require large-scale will and action. This can be done by taking steps to incorporate BIPOC voices in policy decisions, increasing the number of BIPOC professionals in leadership and health equity roles, and providing more opportunities for BIPOC individuals to enter health and medical professions, in particular Black, Indigenous and Latinx individuals focused on pain management practices. In parallel, utilizing an individualized approach to pain assessment and treatment will help clinicians recognize the significance of cultural context in pain coping, pain experiences, and how economic factors such as treatment affordability and access can drive treatment decisions for underrepresented groups.

Training issues are paramount, as effective cultural sensitivity training in the health sciences seems to be uncommon. Numerous calls have been made for the inclusion of anti-racism training within medical school curricula,154-156 as teaching students about issues such as implicit bias, health disparities, and cultural competence has apparently been insufficient. Additionally, aggressive proactive measures should be taken to increase the number of BIPOC health care professionals engaged in pain management. Recent census data estimate that approximately 76% of Americans identify as "non-Hispanic White", with the remaining 24% identifying as BIPOC.157 That roughly 56% of the US physician population identifies as White with the other 44% identifying as BIPOC appears at first glance to be encouraging.158 However, closer scrutiny of these data indicates that only 5% identify as Black and 6% as Latinx, with the aforementioned census data indicating that Black individuals comprise 13.4% of the population and Latinx individuals comprising 18.5%.157 Thus, in medicine broadly, the two most prevalent BIPOC groups are severely underrepresented, and patients within these groups are less likely to have a racially concordant provider than are White patients, which has the potential to result in less favorable pain outcomes.159 Data regarding the representation of Black and Latinx physicians in pain medicine are more elusive, but there is no evidence suggesting greater representation than in medicine, generally.

Given the data indicating that physician-patient race/ethnicity concordance increases patient trust and adherence,160-166 a national effort to produce more BIPOC physicians in primary care and all specialties is essential as our nation's population continues to become more diverse. With concerns regarding adherence associated with opioid analgesics continuing to be prominent, such efforts become even more imperative in pain medicine. Accordingly, consideration should be given to incentivize both undergraduate medical students and residency/fellowship training programs to increase the ranks of BIPOC trainees. Such incentivization would not be without precedent. For example, a 2009 systematic review determined that incentivization programs have resulted in greater numbers of health care providers choosing to work in underserved areas.167 Types of incentives include direct financial incentives, service-requiring scholarships, educational loans with service requirements, loan repayment programs, and service-option educational loans. Incentivizing physicians where to practice, however, has proven easier than incentivizing them regarding what to practice. With the passage of the Affordable Care Act (ACA), the shortage of primary care providers became an even more salient issue, and calls for similar direct and indirect incentivization were made.168,169 Although Primary Care Residency Expansion (PCRE) grants from the Health Resources and Services Administration were temporarily available per the ACA, a 2015 study determined that these time-limited grants were unlikely to increase the flow of medical students into primary care residencies in a sustainable manner.170 Congress has attempted to incentivize the expansion of primary care graduate medical education, yet the offered incentives have offered only minimally financial benefit to those choosing primary care - resulting in the perpetuation of the shortage.171 Additionally, it is in hospitals' best financial interests to train subspecialists for whom their reimbursements will be higher as opposed to primary care residents.172 Accordingly, recent calls for a more direct financial benefit are being made,173 with Ahmed and Carmody recently opining that providing financial compensation or expanding loan forgiveness programs for physicians entering practice in the most needed specialties or areas would create a powerful incentive to encourage doctors to work in the areas of greatest societal need. (p. 5) 172 Given the relative shortage of BIPOC pain physicians, we posit that such direct financial incentivization for BIPOC physicians to enter pain medicine training programs will be imperative as a step toward reducing systemic racism in pain medicine and improving the care that BIPOC patients receive. Similarly, BIPOC nurses, physician assistants, physical therapists, all others who treat chronic pain, and students in these fields should also be directly incentivized to level the playing field. However, more needs to be done in terms of education, beginning in the earliest phases of health care education. Courses covering systemic racism and strategies for overcoming racial/ethnic bias should be provided to both undergraduate and graduate health care students. Although health care curricula deal with the strains of a growing amount of information that needs to be taught in a limited amount of classroom time, the importance of teaching students about the damage unnecessarily caused by systemic racism ought not be understated. Further, continuing education requirements for physicians and allied health providers should include mandatory training in racial/ethnic sensitivity issues. State boards of health care professions have the right to require their licensees to take coursework covering specific topics and do so regularly. For example, 20 state boards currently require a prescribed number of continuing medical education (CME) each renewal cycle on pain management, with many others having requirements for CME specifically on opioid prescribing.174 Should there not also be a continuing education requirement for issues of racial/ethnic bias?

Another strategy for enhancing communication between providers and BIPOC patients is enhanced utilization of culturally competent interpreters when needed. Such practices have strong evidence-bases for improving pain outcomes. For example, a 2012 study of limited English proficiency (LEP) patients found that those provided with access to interpreters reported better quality pain treatment and appeared to result in patients' reports of better communication regarding pain with their providers.175 Additionally, the importance of interpreters having a degree of medical competence as well as bilingual fluency if they are to be effective cannot be understated.176 Even if an interpreter must be used, pain care providers can engage in thoughtful dialogue regarding race and culture with patients and how they play a role in pain management. Doing so can foster trust and engender collaborative treatment decisions, which has been found to be particularly challenging for White providers treating BIPOC patients.177,178 Physicians and other pain care professionals should also be aware of the availability of several useful tools that can aid organizations in bridging language and communication gaps. For example, the National Institute on Minority Health and Health Disparities (NIMHD) has developed a language access portal (LAP) which provides information in several languages specific to conditions identified with health disparities.179 Other useful tools for improving cross-cultural communication with BIPOC patients include the Culturally and Linguistically Appropriate Services (CLAS) standards180 and the National Institutes of Health's HealthReach program for health information in multiple languages.181

Summary and Conclusions

Based on our review, it is clear that the history of systemic racism in pain medicine has been an ugly and unfortunate one, resulting in needless suffering by so many patients simply because of their race/ethnicity. The current Coronavirus pandemic - together with the ongoing protests regarding the need for social justice - has highlighted the persistent detrimental effects of systemic racism, including the impact of long-standing stress and trauma. Yet, we should not lose sight of these unfortunate times representing an opportunity to create sustained and meaningful change toward delivering equitable pain care. Implicit bias remains a contributor to healthcare disparities, broadly. Given that patients suffering from chronic pain are already stigmatized and marginalized, BIPOC chronic pain patients are particularly vulnerable. Provider self-awareness of bias, understanding the cultural context of pain, showing empathy, using a softer tone, listening, and allowing patients to voice their concerns are all important strategies to reduce stress and improve pain management outcomes. On a broader level, evening the playing field will also require the incorporation of BIPOC patients into policy decisions, increasing the availability of BIPOC pain care professionals in the American health care system, and a paradigmatic revision in the models under which pain care professionals are trained. Each of these transformations will be imperative if pain care is to ever adhere to the bioethical principle of justice. Our expectation is not that this analysis will result in an immediate and dramatic revision of the system in which BIPOC patients with pain are treated. However, we are hopeful that by bringing these issues to the attention of policymakers and pain care professionals, the unique plights of BIPOC patients with pain will begin to be more widely recognized and addressed.

Disclosure

Dr Michael E Schatman reports research consultancy for Firstox and Modoscript, outside the submitted work. The authors report no other potential conflicts of interest for this work.

References

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Articles from Journal of Pain Research are provided here courtesy of Dove Press

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Chronic Noncancer Pain Management and Systemic Racism: Time to Move Toward Equal Care Standards

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Although it is widely recognized that the United States has a severe and broad systemic racism problem, recent events have dramatically elevated the issue. Widespread protests in the US and around the world have brought much-deserved attention to the plights of Blacks, Indigenous and People of Color (BIPOC) regarding injustices that they experience on a daily basis.

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17. Evaluating the Impact and Rationale of Race-Specific Estimations of Kidney Function: Estimations from U.S. NHANES, 2015-2018

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17. Evaluating the Impact and Rationale of Race-Specific Estimations of Kidney Function: Estimations from U.S. NHANES, 2015-2018

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Evaluating the Impact and Rationale of Race-Specific Estimations of Kidney Function: Estimations from U.S. NHANES, 2015-2018

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Standard equations for estimating glomerular filtration rate (eGFR) employ race multipliers, systematically inflating eGFR for Black patients. Such inflation is clinically significant because eGFR thresholds of 60, 30, and 20 ml/min/1.73m[2] guide kidney…

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18. Differences in Hypertension Medication Prescribing for Black Americans and Their Association with Hypertension Outcomes

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18. Differences in Hypertension Medication Prescribing for Black Americans and Their Association with Hypertension Outcomes

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Abstract

Background: National guidelines recommend different pharmacologic management of hypertension (HTN) without comorbidities for Black/African Americans (BAA) compared with non-BAA. We sought to 1) identify if these recommendations have influenced prescription patterns in BAA and 2) identify the differences in uncontrolled HTN in BAA on different antihypertensive medications.

Methods: We constructed a linked retrospective observational cohort using 2 years of electronic health records data, comprising of patients aged 18 to 85 with HTN on 1- or 2-drug regimens, including angiotensin-converting enzyme inhibitors (ACE), angiotensin receptor blockers (ARB), thiazide diuretics, or calcium channel blockers (CCB). We examined prescribing differences and HTN control in BAA versus non-BAA.

Results: Among 10,875 patients identified, 20.6% were identified as BAA. 46.4% of BAA had uncontrolled HTN (≥140/90 mmHg) compared with 39.0% of non-BAA ( P < .001). 61.8% of BAA were treated with 1-drug compared with 68.4% of non-BAA. Of BAA on monotherapy: 41.3% were on thiazide, 40.1% on CCB, and 18.6% on ACE/ARB. Of non-BAA on monotherapy, 27.7% were on thiazide, 30.1% were on CCB, and 42.3% were on ACE/ARB. Of BAA patients on 1 drug, 45.2% had uncontrolled HTN compared with 38.0% of non-BAA ( P < .001). Of BAA on 2 drugs, 48.2% had uncontrolled HTN compared with 41.1% non-BAA ( P < .001). For each drug regimen, there was more variation in HTN control within each group than between BAA and non-BAA.

Conclusions: Providers seem to be following race-based guidelines for HTN, yet HTN control for BAA remains worse than non-BAA. An individualized approach to HTN therapy for all patients may be more important than race-based guidelines.

Background

Race-based guidelines for medical care have recently become controversial. Skin color is increasingly recognized as a poor proxy for precision medicine, and many have highlighted the potential harms of using race as a factor in clinical decision-making. For example, well-intentioned medical organizations, relying on data from clinical trials, have long recommended different standards for interpreting kidney and pulmonary function testing for Black/African Americans (BAA) compared with others, even as many have suggested that relying on such guidelines may lead to delayed diagnosis and treatment for BAA populations. In this context, it may be valuable to reevaluate widely accepted race-based guidelines for managing hypertension (HTN) in BAA. The Eighth Joint National Committee in 2014 (JNC8), the American College of Cardiology/American Heart Association in 2017 (ACA/AHA), and European Society of Cardiology 2018 guidelines all recommend a unique approach to initial therapy for BAA, stating that individuals in this group without comorbidities should receive either a thiazide diuretic or a calcium channel blocker (CCB) as initial therapy, whereas angiotensin-converting enzyme inhibitors (ACE) and/or angiotensin receptor blockers (ARB) should be considered as initial therapy only for BAA with certain comorbidities while non-BAA individuals can be prescribed any of those 3 classes of medicines regardless of comorbidities. These guidelines echoed sentiments in the International Society on Hypertension in Blacks (ISHB) consensus statement in 2010 that recommended that first-line treatment consist of a thiazide diuretic or CCB over an ACE/ARB in BAA populations, but not other populations.

Race-based HTN treatment guidelines have been based on evidence from clinical trials and intended to rectify disparities in HTN control in BAA populations. However, the interpretation of this evidence has come under scrutiny. JNC8 and ACA/AHA recommendations are based on results from the Anti-HTN and Lipid-Lowering treatment to Prevent Heart Attack Trial (ALLHAT) and the African American Study of Kidney Disease and Hypertension study (AASK). ALLHAT found in the primary outcome of coronary heart disease there was no difference for BAA when using thiazide, CCB, or ACE. While based on a prespecified secondary outcome of strokes, there was a significant benefit from using CCB/thiazide medications compared with ACE for BAA. However, this finding has been challenged, as the treatment regimen for patients on ACE included a β blocker, which is no longer considered an appropriate regimen for any patient with HTN and no other comorbidities. The AASK Trial evaluated BAA populations with chronic kidney disease and the effects of medications in those populations. While ACE was not as effective at lowering blood pressure (BP) in BAA, it was found that they did prevent the progression of kidney disease. It has been pointed out that avoiding ACE to treat BAA with uncomplicated HTN could lead to worse outcomes for those whose progression of kidney disease is not immediately recognized in primary care.

Given the current concerns about health equity in the United States, we must examine whether and how race-based guidelines for HTN treatment have influenced the practice patterns of primary care clinicians and whether there is evidence of a beneficial impact from following such guidelines on clinical outcomes for BAA with HTN. In this study, our objective was to evaluate electronic health record (EHR) data to identify if these race-based guidelines have influenced health care provider prescribing practices in BAA groups and evaluate the HTN control for BAA and non-BAA patients with uncomplicated HTN who were prescribed 1 or 2 drugs. We additionally examined predictors of uncontrolled HTN among BAA patients.

Methods

Study Design

This study is a retrospective, observational cohort analysis using 2 years of linked EHR data from 3 health systems affiliated with the San Francisco Bay Collaborative Research Network (sfbaycrn.org). The 3 health systems were comprised of 1 academic and 2 county-run systems with a total of 31 primary care clinics. The study included all patients aged 18 to 85 years at the beginning of the study period with a hypertension diagnosis and at least 1 primary care provider care visit between October 15, 2013, and October 14, 2015, for 2 of the 3 health systems, and between May 1, 2014, and April 30, 2016, for the third health system. These 2-year periods were different due to local constraints and Health System 1 to pull data retrospectively to match the dates from the other 2 health systems. All the data were collected using a 1-time extraction of EHR data. HTN diagnosis in each was defined using the Ninth International Classification of Disease visit diagnosis codes 401 and 405 during the study period or a problem list diagnosis indicating "hypertension." Initial exclusion criteria during data extraction were pregnancy-related HTN and end-stage renal disease.

Study Population

For this subset analysis, inclusion criteria encompassed: 1) patients on 1-drug regimens that included either ACE/ARB, thiazide, or CCB; 2) patients on 2-drug regimens on ACE/ARB and/or thiazide and/or CCB. Exclusion criteria included: individuals with diabetes, chronic kidney disease (CKD), not currently on any HTN medications, on 3 or more HTN medications, or 1- or 2-drug regimens including drugs other than ACE, ARB, thiazide, or CCB. Patients with diabetes and CKD were excluded as we did not have data on microalbuminuria, a case in which ACE/ARB are indicated as the first line in BAA populations per national guidelines. Patients on 3 or more medications were excluded as this meets the diagnosis of resistant HTN and is outside the scope of this study. Finally, patients on other medications other than ACE/ARB, thiazide, or CCB were excluded as they are not recommended for initial HTN therapy in any guideline recommendations.

Measurements

The primary outcome was prescription patterns in BAA and non-BAA groups. Our secondary outcome of interest was uncontrolled HTN at a patient's most recent primary care visit, which we defined as a BP reading of stage 2 HTN or greater (≥140/90 mmHg). Controlled HTN was considered Stage 1 HTN or below (<140/90 mmHg). We chose this cutoff because there are multiple recommendations for optimal BP for adults, elderly adults, and BAA in particular. JNC8 guidelines recommend that for adults 18 to 59 years of age, <140/90 mmHg is the ideal goal, while adults 60 years or older without comorbidities should have a treatment goal of <150/90 mmHg. ACA/AHA guidelines recommend a treatment goal for all adults to be <130/80 mmHg regardless of age. The European Society of Cardiology recommends for adults aged 18 to 59 years, treatment goals should be <130/90 mmHg, and for adults 60 years and older, the goal should be <140/90 mmHg. Finally, the ISHB consensus statement recommends a goal BP of <135/85 mmHg in BAA without comorbidities in all ages. We chose our cutoff for all ages because it represented a compromise between the different guidelines, balancing the more stringent ACA/AHA guidelines and the relatively liberal JNC8 guidelines for different age groups. Furthermore, clinician leaders representing these practices settings in our practice-based research network agreed that this cutoff represents a level of control that would be expected to trigger additional intensified medical therapy.

We also collected race and ethnicity (as identified in the EHR), age, sex, body mass index (BMI, calculated from height and weight data), smoking status, preferred language, insurance status, and number of primary care visits during the 2-year study period. Age, BMI, smoking status, and insurance status were collected for the first visit during the study period. For the purpose of this study, a list of all the medications listed as currently prescribed for HTN was pulled in the 1-time extraction of EHR data at the last visit available. Medications (including combination drugs) were broken down into respective medicines and classes.

Analysis

We reported population characteristics stratified by BAA population and non-BAA population. Initial analyses evaluated proportion of cohorts with controlled HTN or uncontrolled HTN on 1- and 2-drug regimens using the proportional z-test. In addition, we examined median systolic and diastolic BP (SBP and DBP) for all participants on each possible treatment regimen, stratified by BAA and non-BAA. We used Pearson's χ ² test for bivariate analysis of categorical data and Student's t-test for continuous data. Multivariate logistic regression models were used to evaluate the association of uncontrolled HTN for both 1- and 2-drug regimens in the BAA subgroup with the following covariates: age as a continuous variable, insurance status (categorical variable: insured, uninsured, and unknown), number of primary care provider (PCP) visits over the 2-year study period (categorical variable: 1 to 2, 3 to 4, or ≥5 visits), and health system where primary care was delivered.

All analyses were performed with SAS 9.4 and STATA 16 data analytics software. The value of P = .05 was used as the cutoff level for statistical significance. Further details on our methods to define our research cohorts and extract/clean/link data from the EHR data can be found in an earlier publication. The Institutional Review Board approved the study at the University of California, San Francisco, with a waiver for informed consent.

To improve transparency, we followed the REporting of studies Conducted using Observational Routinely collected health Data (RECORD) guidelines when presenting our study.

Results

Sociodemographic and Baseline Characteristics

For our subset analysis, 10,875 participants met inclusion criteria. Mean age for this cohort was 56.2 (standard deviation [SD], 12.0) years. The majority (57.8%) of the cohort were female, 94.0% had some form of health insurance (private, Medicare, or Medicaid), and 18.3% were current smokers. One-fifth (20.6%; n = 2245) of the cohort were identified as BAA in the EHR. Of note, a higher proportion of BAA were smokers (38.7%) compared with non-BAA (13.0%) ( P < .001), and a higher proportion of BAA was obese (BMI ≥ 30) (52.2%) as compared with non-BAA (34.9%) ( P < .001). (Table 1).

Pharmacological Treatment Characteristics

Of the total cohort, 67.1% were on 1-drug regimens and 32.9% were on 2-drug regimens. Among BAA patients, 61.8% were on 1-drug and 38.2% were on 2-drug regimens; whereas 68.4% of non-BAA patients were on 1-drug regimens and 31.6% were on 2-drug regimens. Among BAA patients on 1-drug regimens: 41.3% were on thiazide, 40.1% on CCB, and 18.6% on ACE/ARB. Among non-BAA patients on 1-drug regimens: 27.7% were on thiazide, 30.1% on CCB and 42.3% on ACE/ARB. Among BAA patients on 2-drug regimens: 35.8% were on thiazide+CCB, 44.3% on thiazide+ACE/ARB and 19.8% were on CCB+ACE/ARB. Among non-BAA patients on 2-drug regimens: 19.8% were on thiazide+CCB, 49.4% on thiazide+ACE/ARB and 30.8% on CCB+ACE/ARB. ( Table 2)

Median Blood Pressure by Race and by Drug Regimen

Median SBP and DPB for each treatment regimen for BAA and non-BAA populations did not exceed 140 mmHg or 90 mmHg. (Figures 1a There were minimal between-group (BAA vs non-BAA) differences in median blood pressure for any regimen. There was some within-group variation. For BAA patients on 1-drug regimens, those on thiazides had the lowest observed median SBP (134 mmHg), while those on ACE/ARB had the lowest observed median DBP (82 mmHg). For non-BAA patients on 1-drug regimens, those on ACE/ARB had the lowest observed median SBP (133 mmHg), and those on CCB and ACE/ARB had the lowest observed median DBP (79 mmHg). For BAA patients on 2 drug regimens, those on thiazide+ACE/ARB had the lowest observed median SBP (135 mmHg) while those on CCB+ACE/ARB had the lowest observed median DBP 82 mmHg). Among non-BAA patients on 2 drugs, those on thiazide+ACE/ARB had the lowest observed median systolic BP (132 mmHg), while those on CCB+ACE/ARB had the lowest observed median diastolic BP (78 mmHg).

HTN Control by Race

Overall, more of the BAA patients had uncontrolled HTN (BP ≥140/90mmh) compared with the non-BAA patients (46.4%; 95% CI, 0.44-0.48 vs 39.0%; 95%CI, 0.38-0.40; P < .001). Of BAA patients on 1-drug regimens, 45.2% (95% CI, 0.43-0.48) had uncontrolled HTN compared with 38.0% (95% CI, 0.37-0.39) of non-BAA ( P < .001). Of BAA patients on 2-drug regimens, 48.2% (95% CI, 0.45-0.52) had uncontrolled HTN compared with 41.1% (95% CI, 0.39-0.43) of non-BAA ( P < .0001).

Odds of Uncontrolled Blood Pressure among BAA Patients

In our adjusted models, we found that BAA patients on 1-drug regimens including CCB and ACE/ARB medications had higher odds of uncontrolled HTN compared with BAA patients on thiazides (adjusted odds ratio [aOR]=1.53; 95% CI, 1.19-1.97 and aOR = 1.70; 95%CI, 1.25-2.33, respectively). Of BAA patients on 2-drug regimens, there were no significant differences between the 3 treatment combinations. Of note, BAA patients with more than 2 visits to their primary care providers during the study period had significantly lower odds of uncontrolled HTN than those with only 1 to 2 visits. (Table 3)

Discussion

Our study revealed that prescribing practices for uncomplicated HTN were markedly different for BAA versus non-BAA populations in the health systems we examined, with a strong preference for thiazide diuretics and CCB as initial monotherapy and relatively less use of ACE/ARB in 1-drug or 2-drug regimens for BAA patients. This indicates that primary care clinicians in these settings have, to a large extent, been practicing in accord with race-based HTN treatment guidelines that have been developed and disseminated in the last decade. Despite these findings, we also found evidence of continued disparities in HTN control for the BAA group relative to those in the non-BAA group, regardless of the treatment selected. Though BAA patients in this cohort who were prescribed thiazides did have better blood pressure control on average than those on monotherapy with other medications, we did not observe such benefits for individuals prescribed CCB, and across all drug regimens for both BAA and non-BAA, there was far more variation within groups than between groups, suggesting that response to medication prescribed is highly individual, regardless of race.

Our findings suggest that race-based hypertension prescribing guidelines have influenced clinical practice but likely with relatively limited benefit for BAA patients. Other factors may be more important than choice of drug based on skin colors, such as dose titration, the addition of second or third drugs, medication adherence, dietary and lifestyle interventions, such as advocating for smoking cessation, reducing alcohol consumption, and achieving weight loss. Our finding that more frequent clinical follow-up was associated with hypertension control among the BAA patients suggests that there may have been more time during more frequent visits to attend to these important clinical factors.

In addition, social and environmental factors that can contribute to hypertension disparities, such as lack of access to healthy food, unstable housing, social isolation, difficulties paying bills, may also be important risk factors that deserve greater attention. Finally, a factor that deserves specific focus is the role of implicit bias in medicine. It has long been known that race plays an implicit and often negative influence on clinician decision-making. Many studies have shown that BAA often receives poorer care and less referrals than non-BAA populations. At the least, race-specific medication guidelines provide a poor proxy for precision medicine, and at worst they may reinforce negative stereotypes suggesting that BAA patients are both genetically different from other races and that they should therefore be presented with a more limited set of treatment options. These guidelines may also distract clinicians from a more important type of precision medicine, including targeted interventions that address known social determinants of health and a clinician's own implicit biases that disproportionately and negatively impact BAA patients. Furthermore, use of these race-based HTN guidelines could have negative clinical consequences for BAA patients. For example, BAA has up to 4 times the prevalence of CKD, and 1 potential reason could be delayed use of ACE/ARB medications in the early stages of CKD due to reliance on race-based clinical guidelines. Further study is needed to understand if preferentially avoiding ACE/ARB in BAA could contribute to well-documented disparities in long-term HTN outcomes. Finally, BAA patients do not make up a monolithic group; instead, individuals present a rich array of experiences and circumstance, and each person deserves to be treated as a unique individual. Instead of using race as a proxy for precision medicine, we should be searching for more biologically sound pharmacogenomic approaches that are precise and individualized.

Our study, which relies on cross-sectional clinical data, had several limitations. First, our study used EHR reported race/ethnicity. EHR reported race often underestimates BAA race when compared with self-report. Next, we may not have excluded all individuals with comorbidities from our analyses, as the accuracy of such data in the EHR is dependent on clinician documentation. In addition, in our analyses, we did not have access to drug doses or changes in medication prescribing patterns that may have taken place over time. Furthermore, medication lists can be inaccurate due to poor documentation. Another important limitation is this study's inability to control how blood pressure was measured. There are potential differences in how individual health care providers and clinics within and across the health systems collect blood pressure readings. This inconsistency could be reflected in our data. Another consideration is medication adherence. EHR data cannot measure adherence to medication regimens accurately, and this study was not aiming to estimate adherence to medications. However, while these EHR-related limitations are real, they should be evenly spread across the entire cohort and equally distributed across BAA and the non-BAA subgroups. Finally, though the population studied was socioeconomically and racially heterogeneous, our study was conducted in the San Francisco Bay Area, and our findings may not be generalizable to other geographical areas in the United States. Future studies could address these limitations to provide more definitive conclusions to our research questions.

In conclusion, our study shows that while primary care providers often seem to follow race-based prescribing recommendations for HTN, disparities in HTN control for BAA patients relative to other populations persist. While race-based HTN guidelines are well-intentioned, now is the time for more research to understand better the clinical outcomes and possible unintended negative consequences of such guidelines for individuals they are intended to help.

Acknowledgments

The authors would like to acknowledge the clinical leaders and medical informatics teams at each health system without whose participation and assistance this research would not have been possible.

Notes

This article was externally peer reviewed.

Funding: This research was supported by the National Center for Advancing Translational Sciences, National Institutes of Health (UL1 TR001872). JKH was supported by the National Research Service Award (NRSA) grant (T32HP19025).

Conflict of interest: The authors declare that they have no conflicts of interest.

Availability of data and materials: The study protocol, raw data, and/or programing code supporting the conclusions of this article are available from the corresponding author on reasonable request.

To see this article online, please go to: http://jabfm.org/content/35/1/26.full.

Received for publication July 6, 2021.

Revision received August 24, 2021.

Accepted for publication August 25, 2021.

# data[].attributes.attachment_link.title
Differences in Hypertension Medication Prescribing for Black Americans and Their Association with Hypertension Outcomes

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Background: National guidelines recommend different pharmacologic management of hypertension (HTN) without comorbidities for Black/African Americans (BAA) compared with non-BAA. We sought to 1) identify if these recommendations have influenced prescription patterns in BAA and 2) identify the differences in uncontrolled HTN in BAA on different antihypertensive medications.

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19. Racism, Not Race, Drives Inequity Across the COVID-19 Continuum

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19. Racism, Not Race, Drives Inequity Across the COVID-19 Continuum

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Racism - Not Race Drives Inequity Across the COVID-19 Continuum

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21. Demolishing the Myth of the Default Human That Is Killing Black Mothers

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21. Demolishing the Myth of the Default Human That Is Killing Black Mothers

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Independent Researcher, Sacremento, CA, United States

School of Nursing, Department of Family Health Care Nursing, University of California, San Francisco, San Francisco, CA, United States

It took a white police officer's knee on George Floyd's neck before white people began to reckon with 400 years of slavery and its aftermath, the effects of which Black people have endured for generations. Monuments are being taken down, flags are being redesigned, and institutions that honored those who denied the humanity of Black people are being renamed. Unfortunately for Sandra Bland, Breonna Taylor, Sha-Asia Washington and countless other Black transgender people including those with capacity for pregnancy, there was no justice even prior to the global pandemic of SARS-Cov-2 or coronavirus; namely racism, violence, and the Black Maternal Health crisis that makes it less likely that Black women will survive pregnancy and childbirth. The purpose of this article is to situate the state of Black people with the capacity for pregnancy in the context of these existing crises to illuminate the myths that racism has perpetuated through science, health services provision and policy. The greatest of these is the myth of a default human that can serve as a standard for the rest of the population. This racist ideal underpins education, provision of care, research, policies, and public health praxis. Demolishing the myth starts with acknowledging that Black people are not the architects of their own destruction: the default standard of whiteness is. The article begins with a historical background on how this myth came to be and elucidates the development and perpetuations of the myth of the default human. Next, we present an evidence based scoping review of the literature to summarize current thinking with specific focus on the Black maternal health crisis, we make policy recommendations and retrofits of upstream public health approaches for existing programs toward health equity. We also situate Black maternal health as part of a reproductive justice frame that centers Black women and birthing people's autonomy and agency. In other words, we use the scoping review to end with reimagining public health policy and provide an actionable roadmap to specifically disrupt the myth of the default human and dismantle racism in education, provision of care, research, policies, and public health praxis.

Introduction

The myth of a default human posits that white people are the natural reference group for all others when designing scientific studies, reporting scientific findings, allocating human, money and time resources, and that the health outcomes of white people in the United States (U.S.) are the best that can be attained. Demolishing this myth starts with acknowledging that Black people are not the architects of their own destruction: the default standard of whiteness is.

The article begins with a historical background on how this myth came to be and essential definitions. The historical background also elucidates the development and perpetuations of the myth of the default human in published scientific and public health literature. Next, we present an evidence based scoping review of the literature to summarize current thinking with specific focus on the Black maternal health crisis. We seek to clarify key concepts and to identify and analyze knowledge gaps. Finally, we make policy recommendations and retrofits of upstream public health approaches for existing programs toward health equity. We also situate Black maternal health as part of a reproductive justice frame that centers Black women and birthing people's autonomy and agency to illuminate how the myth plays out across the reproductive health spectrum. In other words, we use the scoping review to end with reimagining public health policy grounded in reproductive justice and provide an actionable roadmap to specifically disrupt the myth of the default human and dismantle racism in education, provision of care, research, policies, and public health praxis.

This article is unapologetically specific to understanding the experiences of Black people and how scientific racism is manifest in the conduct of clinical and public health research. We begin with some essential definitions to provide readers with clear meanings as they are used in this article. First, where relevant and appropriate we acknowledge that all pregnant capable people do not identify as women, thus we use gender neutral language to foster inclusivity. Second, when citing historical sources and research literature, we retain the language used by the authors. Third, when using the term Black, we make no distinction across diasporas unless specifically noted. In other words, we do not use African Americans to encompass the range of Black people who originate from other geographies, nor do we use Black and African Americans interchangeably. Fourth, we define Black maternal health as the full spectrum of reproductive health experiences that include the perinatal period of pregnancy, labor, birth, and post-partum; when discussing other pregnancy outcomes (i.e., abortion, family planning, miscarriage, surrogacy) we use the more accurate terminology. When discussing people with capacity for pregnancy or pregnant capable people, who are not currently pregnant, we purposively use these terms as opposed to pre-conception. Finally, we include the word mother in our title out of respect to the family members who intentionally use this term in the context of maternal mortality.

Historical Background

The Black maternal health crisis as we know it today devolved from a system that once deemed Black women the most valuable of all commodities. In 1619, the United States of America was as nascent as its capitalist system, the foundations of which were built on the backs of Africans brought to the Americas as chattel ( 1- 3). After this new nation won its independence, slavery and the growth of capitalism continued hand in hand. Banks, insurance companies, higher education institutions, manufacturing, and health care institutions formed a constellation of enterprises that were created because of and relied on the enslavement of Black people. This began a sustained effort of constructing systems, structures, and policies that inured toward white supremacy and further subjugated Black people.

The U.S. Congress abolished the transatlantic slave trade in 1807 ( 4). However, interstate slave trade was still legal and under U.S. law, the children of slaves were enslaved by birthright. This made Black women's ability to reproduce paramount. Medical journals and planter records in the British West Indies and the United States reveal growing attention paid by White physicians to enslaved women's reproductive lives ( 5). Marie Jenkins Schwartz, in her book, Birthing a Slave: Motherhood and Medicine in the Antebellum South, noted that:

"Although enslaved midwives and nurses supplied much of the daily plantation health care, slaveowners called upon White physicians for cases such as assisting difficult births with forceps, examining the causes of an enslaved woman's infertility, or investigating cases of infant mortality" ( 6).

Such surveillance ensured that enslaved Black women continued to reproduce: Between 1807 and 1860, the number of enslaved Black people in the U.S. increased from just over 1 million to over 3.9 million ( 3). Also see Figure 1.

Figure 1. Trajectory of the Slave Population in the United States (U.S.) from 1790 until 1860. This figure used with permission from (copyleft 2007) Chad David Cover. Data derived from "Series A 119-134. Population by Age, Sex, Race, and Nativity: 1790-1970." U.S. Bureau of the Census, Historical Statistics of the United States, Colonial Times to 1970. Bicentennial Edition, Part 2. Washington, D.C., 1975.

A lesser-known fact is that while enslaved Black women did not have control over their sexuality or ownership of their bodies, they found ways to manage their fertility ( 7). By wresting control over their ability to conceive or to bear a child to full term, they declared their whole humanity and agency over their bodies despite a system that would declare otherwise ( 7). They also defied passing on the birthright of bondage to their children.

Instances of abortion and infanticide are mere mentions in the historical record. According to Deborah Gray White, how enslaved Black women managed their fertility remained a subject discussed only amongst themselves ( 8). What has been gleaned from further analysis of the Works Progress Administration (WPA) slave narratives is that the ingestion of tinctures made from cotton root, was a form of birth control used to prevent conception. Barrier methods were also used and were dangerous forms of birth control that could result in infection and in some cases, death. These were risks that enslaved Black women believed worth taking. In addition to abortion and infanticide, enslaved Black women practiced abstinence which resulted in further, though inconclusive, surveillance by white doctors who came to believe that those women were simply not able to bear children ( 7). These examples serve to teach us that the sexual and reproductive health of Black women and their enslaved ancestors is underexamined in historical records. It matters to point these exemplars out to disrupt the myth of the default human: Concerns about reproductive healthcare and injustice did not originate with narratives that are grounded in bra burning and the sexual "revolution" associated with second wave white feminists ( 9).

The abolition of slavery and the failure of Reconstruction demanded that a hierarchy of humanity be reasserted. While chattel slavery was no longer part of the capitalist system, Jim Crow laws became its proxy, denying freed slaves the rights secured by whites. Laws that mandated segregation based on race gave rise to the development of new systems and structures that excluded Black people. The 1856 ruling in Scott v. Sandford ( 10) was a bellwether. Central to Scott v. Sanford was Justice Taney's belief that "Black people had no rights that white men were bound to respect," therefore codifying a racist system of laws established after emancipation ( 10).

If Scott v. Sanford built the table, Plessy v. Ferguson ( 11) provided the bounty for separate but equal. In 1896, the U.S. Supreme Court ruled against the challenge brought by Homer Plessy that segregation based on race was a violation of the equal protection clause of the 14th Amendment. By ruling in favor of separate but equal accommodations, the Supreme Court essentially relegated Black people to second-class citizenry. The impact of legalized racial segregation and resulting lack of investment in equal housing, education and healthcare for Black people is multi-layered, multi-generational, and profound ( 12). It is especially broad and deep with regard to access to healthcare, health provision, and the education and training of healthcare professionals.

Limited access to quality public education has had the most profound effect on Black people's health outcomes. After emancipation, the sharecropping system kept Black families in poverty and truncated secondary education. While land grant institutions were founded to educate freedmen, there were many barriers to medical education for Black people, including affordability and access. Racial segregation and structural racism also limited access to residency and specialty fellowship programs. In response to these barriers, a movement to train more Black physicians resulted in the founding of 14 medical schools between the late nineteenth century and early twentieth century. While it has been argued that a few of those schools may have been established as diploma mills that did nothing to advance the cause of medical education for Black people, it is also important to note that most of them were underfunded, lacked adequate facilities, and had limited access to patients ( 13).

Abraham Flexner in his report ( 14) commissioned by the Carnegie Foundation in 1910, emphasized the need for improvements in medical education. Flexner visited 155 medical school in 18 months, citing Johns Hopkins Medical School as the standard that medical education should emulate ( 13). This standard was nearly impossible to meet for medical schools founded to educate Black people. Of the fourteen medical schools founded for that purpose, only two survived: Howard University School of Medicine and Meharry Medical College, which before 1960 had graduated nearly all the Black physicians who received training in the U.S. ( 15).

Flexner's goal, to improve the quality of medical education, came with a consequence that the healthcare enterprise continues to reckon with. The closure of medical schools founded to educate Black people who were refused admission to majority-white institutions, coupled with the closure of majority institutions that also did not meet the standards that Flexner set, placed medical education further out of reach, especially for Black students. There have been just two Black medical schools founded in the last 100 years: Charles Drew Medical School and Meharry Medical School and <4% of physicians in the U.S. are Black, while Black people make up 13% of the population ( 13).

Dr. Charles H. Epps, renowned orthopedist, put a finer point on the impact of Flexner's work. In his article, Perspectives From the Historic African American Medical Institutions ( 16), he wrote that Howard University and Meharry Medical School educated ~85% of all African American physicians whereas the majority medical schools educated 15% for more than half of the twentieth century. Drawing from a 1975 study, Effects of affirmative action in medical schools, Dr. Epps also pointed out that minority physicians, especially African American physicians, tended to provide services in their own communities that are competent and culturally sensitive ( 17).

For Black people, "The opportunity to train to be a physician is still not where it should be," Dr. Ed Harley told MedPage Today. "More than 100 years later, we are still trying to make up for the deficit" ( 18).

On the heels of Flexner's report came another set of standards developed without regard for, or understanding of, the historically and culturally relevant experiences of Black women. The Sheppard-Towner Act ( 19) was birthed after intense lobbying by middle class white women with a progressive agenda for establishing standards to reduce maternal and infant deaths ( 20). Their work paid off when first, in 1912, the federal government established the Children's Bureau. The Children's Bureau worked with states to track birth and death records under the Sheppard-Towner Maternity and Infancy Act that followed in 1921 ( 20). Additionally, the Act provided states with federal funding to improve maternal and childcare through education, training and licensing of midwives as well as the establishment of hygiene and other standards. Midwifery was largely concentrated in the rural South where Black (grand) midwives were the majority. Under the scrutiny of Sheppard-Towner, grand midwives were deemed ignorant, dirty, dangerous and prone to superstition ( 21). The American Medical Association's powerful lobby against the Act due to a fear of government control over the medical profession, was a factor that led to its repeal in 1929 ( 21). By then the damage was done to Black midwifery: the narrative about the lack of hygiene and cleanliness of Black midwives and Black mothers remained the frame through which Black midwives were trained and through which Black women would continue to be judged as dangerous and not to be trusted.

In her ground-breaking work, Medical Bondage: Race, Gender, and the Origins of American Gynecology, Dr. Deirdre Cooper-Owens outlines the important connection of these actions on the health of Black people. In a follow-up article for the American Journal of Public Health, she writes:

"Explicit segregation in the realm of health care remained completely intact until the mid-1960s. In 1964, Congress passed the Civil Rights Act, which prohibited federally funded programs and institutions from discriminating on the basis of race. The following year, Congress created the Medicare Program, which made almost all hospitals the recipients of federal funding. As a consequence of their participation in the Medicare Program, almost every hospital in the U.S. was forced to abide by the provisions of the Civil Rights Act of 1964. Despite attempts to prevent racial integration, medical facilities eventually came to treat patients and hire doctors of all races" ( 5).

While the Civil Rights Act ended de facto segregation, it did not change the fact that Black people were at the bottom of the hierarchy of humanity. As such, they continue to experience seemingly intractable health disparities. In examining the clinical, research and education enterprises within healthcare, these disparities are the result of systematic and intentional adherence to standards built with and toward the exclusion of Black people. Paradoxically, the default standard of whiteness used as the exemplar in the healthcare is also a damnable one: One of the most profound disparities- the high rate of Black women dying during or soon after childbirth- threatens the very ability for Black people to reproduce.

Scoping Review of the Literature

The process of naming, defining, and documenting a longstanding myth of a default human-that white people are the natural reference group for all others when designing scientific studies, reporting scientific findings, allocating human, money and time resources and that the health outcomes of white people in the U.S. are the best that can be attained-requires rigorous methods. The study of race and racism crosses multiple domains including the arts and humanities, clinical health services provision, healthcare, history, psychology, public health, and sociology. Despite recent attention to health disparities ( 22), health inequities ( 23), and anti-racism efforts ( 24), the boundaries of these domains of knowledge are unknown. To avoid replicating one common mistake of retrofitting new knowledge onto existing science, (i.e., conducting a narrowly defined systematic review), we believe a scoping review of literature is a better approach to synthesizing the myth in context.

The purpose of scoping reviews has been described as the following: (1) To identify the types of available evidence in a given field; (2) To clarify key concepts/definitions in the literature; (3) To examine how research is conducted on a certain topic or field; (4) To identify key characteristics or factors related to a concept; (5) As a precursor to a systematic review; and (6) To identify and analyze knowledge gaps ( 25), We believe the Black Maternal Health crisis in the U.S. provides a clear exemplar of the manifestation of the myth of the default human. Additionally, given the complexity of how Black maternal health spans social and structural determinants of health, public health, medicine, nursing, health policy, we consider a scoping review as essential to clarify key concepts (i.e., myth of default human and where it manifests) and to identify and analyze knowledge gaps specific to necessary interventions resolve health inequities.

Materials and Methods

The purpose of the scoping review was two-fold. The first was to clarify key concepts, which requires articles that report data comparing either among Black people and/or between Black people and people of other races to meet inclusion criteria. The second was to achieve our goal of identifying and analyzing knowledge gaps, therefore articles needed to either include interventions in their research methods, report evaluation of interventions, or discuss interventions or mitigation of harm in the section Discussion. Maternal mortality was used as the primary Medical Subject Headings (MeSH) search term including sub-headings of morbidity. The authors conducted the scoping review between December 2020 and February 2021.

Inclusion criteria for the scoping review included articles specific to Humans, published in English and any study conducted and published from any time period with data from people aged 13 to 65 years of age. There were no limitations on the types of research methods used by research teams. Studies reporting individual, community, or neighborhood level data were included. Exclusion criteria included animal studies, studies in languages other than English, systematic reviews of pregnancy outcomes, methodology or methods articles, studies without analyses of African American or Black participants. An additional exclusion criterion was any pregnancy mortality that was not the result of an intended birth, specifically studies describing gestational trophoblastic disease and abortion. Gestational trophoblastic disease is managed as malignancies in oncology and abortion related mortality has been known to be rare, particularly after decriminalization codified in Roe vs. Wade in 1973.

Given the specific focus of racism how and how it operates in the U.S., studies including data from international geographies outside of the U.S. were excluded. However, we acknowledge that the myth of the default human grounded in white supremacy and racism are not exclusive to the U.S. Risk categorization was not considered as an inclusion or exclusion criteria since it is already known that education, income, social and marital status do not impact maternal mortality among Black women-risk is equitably shared regardless of these demographic characteristics.

Phase I of the scoping review was conducted to clarify concepts and was completed in January 2021 that included articles using the Pubmed MeSH topic maternal mortality with no filters and this search resulted in 1,750 articles ranging from 1958 to 2021. When the filters of Human, English language, and ages 13-65 years were set, this reduced the articles to 664. When the word Black was applied to this search that yielded 664 articles, the number reduced to 38 articles published between 2000 and 2021. When the term African American was applied to the search that yielded 664 articles, the number reduced to 24 articles published between 2000 and 2021. The MeSH search lists (including African American and Black in the search terms) were merged and resulted in 38 articles. All abstracts were retrieved, reviewed and 26 met inclusion criteria for the scoping review. Nine articles were excluded because their study populations were in geographies outside of the U.S, and one article was excluded because it was a news report in a scholarly journal. One abstract could not be obtained. An additional article was excluded because it reported updates in gestational trophoblastic disease-a pregnancy outcome managed differently than birth. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) for Scoping Review Phase I appears in Figure 2.

Figure 2. PRISMA for Scoping Review Phase I-Clarify Concepts.

Phase II of the scoping review was to identify and analyze knowledge gaps. This review, conducted in February 2021, included articles using the Pubmed MeSH topic racism with no filters and the addition of maternal mortality yielded no results. When pregnancy was used instead, this search resulted in 59 articles ranging from 2012 to 2021. No filters were used, and all abstracts were retrieved, reviewed, and 42 met inclusion criteria for the scoping review. Fifteen articles were excluded as the study populations were in geographies outside of the U.S. Three articles did not include Black or African American participants. Two articles were an interview of a single person, and one systematic review of racism and pregnant youth was excluded. Five of the 42 articles included in this scoping review are evidence-based or historical commentaries that use data to make important points specific to interventions and mitigation of harm. The PRISMA for Scoping Review Phase II appears in Figure 3.

Figure 3. PRISMA for Scoping Review - Phase II - Knowledge Gaps.

In lieu of generating summary statistics, we read each article to synthesize the concepts within and across studies. We used procedures included in thematic analysis methods ( 26) including familiarizing ourselves with the data; however, instead of generating initial codes, we extracted data for clarifying key concepts specific to establishing the presence/absence of the myth of the default human. By reviewing the full text of the articles that met inclusion criteria, we were able to document themes of each study. We categorized each study based on the type of data that were reported (i.e., individual level data, population level data, and state level data) to determine if these factors impacted the generation of themes. While reviewing themes of each study, we defined, named and categorized themes across studies, allowing us to identify and analyze knowledge gaps.

Results

A total of 67 published manuscripts combined from Phases I and II were used for this scoping review that includes data that represent both qualitative and quantitative research methods ( Supplementary Tables 1-6). Beginning from the foundational work of Guyer et al. ( 20) which provides the annual summary of vital statistics and trends in the health of Americans during the entire twentieth century, we begin to see the manifestation, development, and perpetuation of the myth of the default human. The a priori categorization of the studies by data level (i.e., individual level data, population level data, and state level data) did not alter the themes, however, for ease of reading grouping them allowed us to determine the elements of the myth of the default human. Themes from the scoping review ( Table 1) show there are four elements that are endemic to the maintenance of the myth of the default human that are perpetuated by descriptions of disparities-without testing interventions for mitigation. These elements include (1) Data; (2) Lack of accountability for generation and perpetuation of blame narratives; (3) Life course approaches are under-utilized in study designs; (4) Interventions focus on leveraging existing structures that are inequitable retrofits.

Table 1. Thematic analysis of scoping review by phase.

In the Phase I analysis specific to clarifying concepts two themes were identified, data and lack of accountability for generation and perpetuation of blame narratives. Within the data theme were most studies that attempt to define, make sense of, and determine who is measured, when, where, and how. The sub-themes of data are indicative of not having comprehensive national data to understand maternal morbidity and mortality and reflect the limitations of study design when using administrative or publicly available administrative or claims data sets. Specific to lack of accountability, there are several issues that are determined by the fact that Black women and pregnant capable people are not routinely consulted as experts on their own health, nor are their specific research interests reflected in the published literature. Intervention studies are sparce and inadequate because they are focused on leveraging existing structures that are inequitable retrofits (Phase II gap). It is important to note that the bulk of scholarly contributions included in this scoping review have been published within the last 10-20 years (despite no search limits specific to time), reflecting a lack of attention to maternal health more broadly and Black maternal health specifically.

Phase II of the scoping review specific to identifying gaps again focused on data and study design-specifically since the middle-class, white heteronormative gaze is apparent in research questions, the determination of outcomes and exposures without every accounting for the realities of Black life, structural racism, and resilience factors of communities. Additionally, life course approaches were under-utilized in study design. Taken together, one unfortunate conclusion that could be drawn from this scoping review is that the increase in Black maternal death did not draw attention until the data began to indicate an increase in white maternal death. An additional finding from this scoping review suggests the need for a reimagining of education, health services provision, research, and policy specific to the reproductive life courses of Black women and birthing people. Much of the published research treats Blackness as a universal characteristic, with little to no attention to the intersections of class, or income. Despite the fact that it is already known that risk for Black maternal death is equitably shared, interventions have specifically focused on low-income individuals and/or those using publicly funded insurance or services. Given the historical grounding that opens this piece, it should be obvious that the public infrastructure has been inadequate to meet the health needs of Black people. Therefore, to address the findings of the scoping review, that include patients, people, seeking services, as well as clinical treatment and procedures, in context of the historical data presented in the introduction, we propose adopting reproductive justice as a foundational and theoretical frame for intervention research. This path forward should begin essential work to resolve the myth of the default human in the context of maternal morbidity and mortality.

Discussion

So, what is the way forward? How do we dismantle the myth of the default human and what will it take to build new standards in education, provision of care, research, policies, public health praxis, and workforce development, and ultimately improve Black maternal health outcomes? First, we must acknowledge that the people most impacted by health disparities are best positioned to determine the solutions. This means that Black communities and Black women specifically need to be centered and prioritized in discussions and decisions about Black maternal health. This includes the mapping of assets, and the development and testing of interventions. Best practices and standards in the conduct of research with, for, and by Black mamas have been proposed to improve the quality of research questions that decenter whiteness ( 27). Next, curricula need to reflect the knowledge production of Black communities and their experiential wisdom. It is disingenuous that patient medical history remains a gold standard of health information gathering, but patient voice is missing from the education and training of the future health care workforce. Third, community-generated big data are essential for research that is conceptualized, operationalized, and actualized with, for, and by Black women. Finally, clinical care needs to be provided by a racially, culturally, and socially concordant workforce. Intentional investment in the healthcare workforce in Black communities that experienced divestment after the Flexner report was released in 1910, is one right place to start.

Recent Developments and Action Steps

Adopting reproductive justice is an essential component for the design of all clinical health services and educational programs. Specifically, understanding every person has a human right to maintain personal bodily autonomy, have children, not have children, and parent the children we have in safe and sustainable communities ( 28). If we are to achieve reproductive justice, we can no longer afford to risk the lives of Black women and birthing people based on a mythical standard. Healthcare providers, researchers and scholars, policymakers, and philanthropists-all who have a stake in addressing this crisis-must listen to Black women and birthing people if we are to reduce maternal deaths. We must also remedy the divestments in the social safety net following Reconstruction, the Civil Rights movement, and most of the Reagan era. We cannot allow for a return to complacency if and when we start to see declines in Black maternal morbidity and mortality. History teaches us that any new path forward should center those who are the most marginalized if we are to improve health outcomes for all people with the capacity for pregnancy.

The preservation of Black maternal health is just one aspect of reproductive justice that not only calls for accountability but also requires radical reimagination. This radical reimagination centers Black women, trusts Black women, and invests in Black women. Imagine this: the solution to reducing Black maternal mortality and morbidity already exists within the community that carries the greatest burden. Imagine if Black women defined for themselves the standards by which their agency is measured. Imagine if they harnessed that same self-determination and agency that would have enslaved Black women control whether they would bear a child conceived in rape, to carry and give birth to a much-wanted child to term without sacrificing her life. Imagine if cultural rigor- the operationalization of critical race theory, reproductive justice, research justice, and big data intersected with health services provision, health services research, quality improvement, and health care policy-was used to build those new standards ( 29). Imagine if the forces that have kept Black people from extinction were better understood and leveraged to improve Black maternal health outcomes.

Recent developments have provided some cause for optimism including a recently announced public-private partnership that was established to address maternal morbidity and mortality from the Department of Health and Human Services, The Office of the Surgeon General, and the March of Dimes ( 30). Additionally, for the first time since its inception in 2018, a Presidential Proclamation was issued to establish April 11th through April 17th as Black Maternal Health Awareness week ( 31). Finally, funds were included as part of the American Rescue Plan, for post-partum Medicaid expansion to address preventable maternal mortality-which is known to disproportionally occur in the post-partum period ( 32).

Additional action steps should include:

* Targeted Investments in Black Students, Educators, Healthcare Providers, and Researchers

* Targeted Investments in the Social Safety Net and Black Communities

* Establishing Community Engagement as a Default Mechanism of Accountability

* Center the Voices, Strategies, and Interventions of Black Birthing People

* Retrofit, Reform, and Reimagine Clinical Health Services Provision, Education, Research, and Policy Development

* Establish Authentic Partnership with Black Women and Femme led Organizations as Leaders of the Work to Reduce Maternal Morbidity and Mortality

* Believe When Interventions are Developed and Implemented to Improve Black Maternal Health that the Health of All Populations Will Improve.

There are limitations and strengths to this work that need to be acknowledged. First, this work is limited to history documented by individuals immersed in and responding to the myth of the default human. We have paid close attention to our citational practices to center the perspectives of Black authors and scholars. Next, articles included in the scoping review were exclusive to those published in English-which misses nuance of Black or African American experiences of people who use speak other languages. Recent work has focused on colorism and the domains of racism and discrimination and this scoping review was unable to be as granular in our analysis-although some of those citations do appear in the review. Finally, we do not proport to have mapped all dimensions of the evidence of the myth of the default human in health services, education, research, and policy related publications. The limited purpose of the scoping review was to clarify concepts and identify gaps to make recommendations about areas where public health interventions could be reimagined.

Conclusion

In conclusion, we have read or heard countless stories of Black women who have nearly died or have died during or after childbirth. We know them. They are our friends, our neighbors, our co-workers, our family members, and our partners. While we know that higher socioeconomic status is a predictor of health outcomes, this couldn't be further from the truth when it comes to Black maternal health outcomes. How much money or education Black people have, how they construct families, what they wear, their hairstyles, diction, and their very breath are constantly under assault even as Black people aspire to be the "right" kind of people as defined by the default standard of whiteness. It begs the question of whether any default standard is the right exemplar for preventing Black maternal death when we examine the maternal health outcomes in lower income countries where the default standard is not whiteness ( 29). Too many scholars have been content to describe disparities in reproductive health outcomes specific to Black maternal health, and yet far too few have examined interventions to mitigate the associated drivers of disparities and inequities. Further, the healthcare enterprise continues to dismiss Black maternal agency by perpetuating narratives (e.g., older, sicker, fatter) that place the blame for poor maternal health outcomes on Black mothers ( 33). Included in that narrative is non-compliance, a by-product of medical mistrust due to racial discrimination ( 34, 35). None of these approaches appropriately represent the experiences, satisfaction, or quality of Black life or wellness. The inability for research, education, policy or clinical practice to encapsulate or even imagine Black humanity as unique and distinct from the myth of the default standard of white people cannot continue and should be designated unethical. As Katherine McKittrick has outlined in her recent book entitled Dear Science, we observe that "the project of making discipline overwhelmingly only gives us two options for the study of Black people-to describe racism and resist racism; these options rarely have any noise or curiosity or questions about Black life interrupting them" ( 36). We wholeheartedly agree and call upon those in education, provision of care, research, policies, and public health praxis to consider actively dismantling of the myth of the default human-it is not the best that can be attained and new futures remain limited by its continued existence.

Author Contributions

MM co-wrote this manuscript with SB, principal-Black Women Write. Both authors conceptualized, wrote, and analyzed the data in this manuscript.

Funding

Institutional funds to MM for open source publishing will be used to support this work. The funder had no influence over the work being presented.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Supplementary Material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpubh.2021.675788/full#supplementary-material

References

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3. Kendi IX. Stamped From the Beginning: The Definitive History of Racist Ideas in America. New York, NY: Nation Books (2016).

4. 13th Amendment to the U.S. Constitution: Abolition of Slavery. U.S. Congress and Senate.

7. Perrin L. Resisting reproduction: reconsidering slave contraception in the old South. J Am Stud. (2001) 35:255-74. doi: 10.1017/S0021875801006612

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9. Hamad R. White Tears/Brown Scars: How White Feminism Betrays Women of Color. New York, NY: Catapult (2020) Chapter 1; Chapter 5.

11. U.S. Reports: Plessy v. Ferguson, 163 U.S. 537. U.S. Congress and Senate (1896).

19. The Promotion of the Welfare and Hygiene of Maternity and Infancy Act (more commonly known as the Sheppard-Towner Act). U.S. Congress: 42 Stat. 224, Chap: 135.

25. Munn Z, Peters MDJ, Stern C, Tufanaru C, McArthur A, Aromataris E. Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approach. BMC Med Res Methodol. (2018) 18:143. doi: 10.1186/s12874-018-0611-x

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Demolishing the Myth of the Default Human That Is Killing Black Mothers

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It took a white police officer's knee on George Floyd's neck before white people began to reckon with 400 years of slavery and its aftermath, the effects of which Black people have endured for generations. Monuments are being taken down, flags are being redesigned, and institutions that honored those who denied the humanity of Black people are being renamed.

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22. MATERNAL AND INFANT HEALTH INEQUALITY:NEW EVIDENCE FROM LINKED ADMINISTRATIVE DATA

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22. MATERNAL AND INFANT HEALTH INEQUALITY:NEW EVIDENCE FROM LINKED ADMINISTRATIVE DATA

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23. Effects of Race, Workplace Racism, and COVID Worry on the Emotional Well-Being of Hospital-Based Nurses: A Dual Pandemic

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23. Effects of Race, Workplace Racism, and COVID Worry on the Emotional Well-Being of Hospital-Based Nurses: A Dual Pandemic

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Effects of Race Workplace Racism and COVID Worry on the Emotional Well Being of Hospital Based Nurses A Dual Pandemic

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24. Risk of COVID-19 among front-line health-care workers and the general community: a prospective cohort study

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24. Risk of COVID-19 among front-line health-care workers and the general community: a prospective cohort study

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Risk of COVID-19 among front-line health-care workers and the general community: a prospective cohort study

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In the UK and the USA, risk of reporting a positive test for COVID-19 was increased among front-line health-care workers. Health-care systems should ensure adequate availability of PPE and develop additional strategies to protect health-care workers from COVID-19, particularly those from Black, Asian, and minority ethnic backgrounds.

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25. COVID-19 deaths analyzed by race and ethnicity - APM Research Lab

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25. COVID-19 deaths analyzed by race and ethnicity - APM Research Lab

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You value and rely on the work of the APM Research Lab. And we rely on you, especially
during this difficult time. If you can, please support our work with a donation today.

Our ongoing Color of Coronavirus project monitors how and where COVID-19 mortality is inequitably impacting certain communities-to guide policy and community responses to these disproportionate deaths. The coronavirus has claimed more than 240,000 American lives through Nov. 10, 2020-nearly 25,000 more than our last update four weeks ago. We have documented the race and ethnicity for 96% of the cumulative deaths in the United States.

Our latest update reveals that Black and Indigenous Americans continue to suffer the greatest loss of life-with both groups now experiencing a COVID-19 death toll exceeding 1 in 1,000 nationally.

We also adjust these mortality rates for differences in the age distribution of populations, a common and important tool that health researchers use to compare diseases that affect age groups differently. At the national level, this results in even larger documented mortality disparities- Black, Indigenous and Latino Americans all have a COVID-19 death rate of triple or more White Americans, who experience the lowest age-adjusted rates.

The APM Research Lab has independently compiled these death statistics. ( Learn more about how.) The result is the most robust and up-to-date portrait of COVID-19 mortality by race available anywhere, with a lens on inequitable deaths. We are now presenting mortality data over time for all states -not just cumulatively-to help us monitor the virus' changing impacts throughout fall and winter. We have been tracking these deaths for seven months now, revealing COVID-19's growing toll on all Americans, but with the heaviest losses among Black, Indigenous and Latino Americans.

KEY FINDINGS (from data through Nov. 10):

Of the more than 240,000 U.S. deaths catalogued in this Color of Coronavirus update, this is the number of deaths documented by group through Nov. 10, 2020: Asian (8,687), Black (46,211), Indigenous (2,251), Latino (46,912), Pacific Islander (334) and White (123,429). Additionally, 5,373 deaths are recorded only as "other" race (and likely include more Indigenous people and Pacific Islanders), while another 8,510 had an unknown race.

In the past four weeks, the death rate among Indigenous people has accelerated the fastest (shown by a steeper slope in the graph above).

These are the documented, nationwide actual mortality impacts from COVID-19 data (aggregated from all U.S. states and the District of Columbia) for all race groups:

1 in 875 Black Americans has died (or 114.3 deaths per 100,000)

1 in 925 Indigenous Americans has died (or 108.3 deaths per 100,000)

1 in 1,275 Latino Americans has died (or 78.5 deaths per 100,000)

1 in 1,325 Pacific Islander Americans has died (or 75.5 deaths per 100,000)

1 in 1,625 White Americans has died (or 61.7 deaths per 100,000)

1 in 2,100 Asian Americans has died (or 47.6 deaths per 100,000)

Black Americans continue to experience the highest actual COVID-19 mortality rates nationwide-about two or more times as high as the rate for Whites and Asians, who have the lowest actual rates. Indigenous Americans' death rate is just slightly lower than Blacks.

If they had died of COVID-19 at the same actual
rate as White Americans, about 21,200 Black,
10,000 Latino, 1,000 Indigenous and 70 Pacific Islander Americans would still be alive.

Adjusting the data for age differences in race groups widens the gap in the overall mortality rates between all other groups and Whites, who have the lowest rate. It also reveals that Indigenous people have suffered the greatest losses, accounting for age differences, followed closely by Blacks and Latinos. Compared to Whites, the latest U.S. age-adjusted COVID-19 mortality rate for:

Indigenous people is 3.2 times as high

Blacks is 3.0 times as high

Latinos is 3.0 times as high

Pacific Islanders is 2.3 times as high, and

Asians is 1.1 times as high.

(A fuller discussion of our indirectly age-adjusted rates follows.)

HOW TO EXAMINE THE DATA:

1. EXPLORE CUMULATIVE MORTALITY RATES BY GEOGRAPHY, COMPARING GROUPS

We've presented the data we've collected for the nation overall and each state as:

2. EXPLORE NUMBER OF DEATHS OR RATES OVER TIME, COMPARING GROUPS

Explore actual mortality rates and total deaths by race and ethnicity for any state or Washington, D.C., beginning in early June 2020.

3. EXPLORE CUMULATIVE FINDINGS BY GROUP, COMPARING GEOGRAPHIES

Examine the differences for one group at a time across all states with available data. For each group, we provide contextual data and a visual comparison against White Americans' rates using the age-adjusted data, to examine where disparities relative to Whites are the greatest.
For more context about the shortcomings of some of the data, please read our note about Indigenous, Pacific Islander, Multiracial and Other Race Americans. If you'd like to examine the percentage of deaths compared to the percentage of population by racial group for each state (which previously appeared on this site), you can find this data in our complete data file.

&plus; Understanding Age-Adjusted Mortality Rates

Click to read more

While there are many features of the novel coronavirus that are still unclear, this we know with certainty: The risk of dying from COVID-19 rises sharply with advanced age. Fewer than 4 in 100,000 Americans under age 45 have died from the virus, according to data submitted to the CDC through Oct. 31. The COVID-19 death rate for Americans age 45-54 rises to 28 per 100,000; more than doubles for those age 55-64 (65 per 100,000); and more than doubles again among those age 65-74 (154 per 100,000). Among Americans age 75 and older, the death toll is exceedingly high: 571 people per 100,000, as shown below.

Due to this steep age gradient to COVID-19 mortality, it is important to consider the varying age distributions of America's racial and ethnic groups. A higher share of White Americans are in the older age brackets than any other group. To illustrate this, consider that the median age of non-Hispanic White Americans is 44 years, according to the latest Census Bureau data. The comparable figure for all populations of color is considerably lower-for Asians (37), Blacks (34), Pacific Islanders (33), Indigenous (32) and especially Latinos (30), half of whom have not yet reached their 30th birthday.

Even within the same race groups, the age distribution varies-with retirement destination states such as Florida having a much higher share of older adults within their White population, for example.

Black, Indigenous and Latino Americans all have a COVID-19 death rate of triple or more the rate of White Americans (age-adjusted).

So, to remove the role of age differences from COVID-19 mortality rates, we have also produced age-adjusted rates. Because mortality data is not available for all states by race and age jointly (which is preferred), we have used indirect standardization to calculate these rates. See our NOTES section for details and cautions about our method.

Adjusting the racial data we've collected for age differences increases the COVID-19 mortality rate for all racial and ethnic groups except for Whites, who experience a decrease, as shown below. Latinos' rate rises the most following age-adjustment, revealing that the virus is impacting Latinos far more than would be expected based on their youhtful age profile.

After age-adjusting, the gap between Black and White mortality widens-from 1.9 to 3.0 times as high. Relative to Whites, mortality rates for Indigenous people also rise to 3.2 times as high (the highest rate) and Latinos to 3.0 times as high. Rates for Pacific Islanders also grow, to 2.3 times as high as Whites. Finally, the Asian mortality rate-which was slightly below the White rate-rises slightly above the White death rate (1.1 times as high), when age is taken into account. Put another way, Indigenous, Black and Latino Americans all have COVID-19 death rates of triple or more the rate of White Americans (age-adjusted).

What does this mean? It indicates that many younger Americans who are Black, Latino, Indigenous or Pacific Islanders are dying of COVID-19-driving their mortality rates far above White Americans'. Despite their relative youthfulness (a protective factor against COVID), their death rates are elevated. As Brookings Institution has reported, "In every age category, Black people are dying from COVID at roughly the same rate as White people more than a decade older."

It is important to note that, while age-adjusted mortality rates help us remove the influence of age differences in racial groups to examine disparities in outcomes, they are not the actual mortality rates experienced by these groups.

CUMULATIVE MORTALITY RATES

Review cumulative mortality rates-both actual and age-adjusted-for the District of Columbia or any state by changing the dropdown menu below. Rates were not calculated when there were fewer than 15 deaths for a particular group (resulting in a "0" value in the graph below). Rates for Indigenous and Pacific Islander residents could only be calculated for some states. Additionally, rates were not calculated for multiracial people, nor those identified as "Other" race.

ACTUAL MORTALITY RATES OVER TIME

REPORTED DEATHS BY RACE & ETHNICITY OVER TIME

Explore how the distribution of American lives lost varies by race and ethnicity for all states, beginning with totals in early June. Select a state to see the cumulative trend graphed similarly.

Users can examine the cumulative death totals, grouped by racial and ethnic group, for their state(s) of interest below. Depending on the geography, the "Other" group in this graph may include Indigenous people, Native Hawaiian or other Pacific Islanders, Multiracial people, those identified as "Other" race, and in a few cases, Asians. (This is due to uneven reporting by states.) Please see the notes below the graph, or request our complete data file for additional information.

Search by state

(Use Shift + Ctrl to select more than one state)

COVID-19 deaths by race and ethnicity, through Nov. 10, 2020

FOCUS ON BLACK AMERICANS

Lives lost to date

Actual mortality rate

Age-adjusted mortality rate

NOTE ABOUT INDIGENOUS, PACIFIC ISLANDER, MULTIRACIAL & OTHER RACE AMERICANS

COVID-19 mortality data for Americans who are Indigenous, Native Hawaiian or Other Pacific Islanders, Some Other race, or Multiracial is inconsistently reported by many states. Users may request our complete data file to better understand the loss of life in these groups as well. Users are cautioned that Indigenous and Pacific Islander people appear in the "Other" group in many states, along with Multiracial Americans and in a few cases, Asian Americans. We continue to advocate for complete, consistent reporting for all racial and ethnic groups.

HOW DID THE APM RESEARCH LAB OBTAIN THE DATA?

The APM Research Lab has independently compiled and analyzed these mortality data for Washington, D.C. and all states. At the time of this writing, only North Dakota and West Virginia did not yet publicly release COVID-19 mortality data by race and ethnicity on their state health department websites. For these two states, we have supplemented our data file using data reported to the National Center for Health Statistics, a division of the CDC. Note that these data have some time lag and often suppress data (i.e., hide for privacy's sake), especially for groups other than Whites. Nonetheless, their inclusion improves the picture of COVID-19 mortality for the entire United States.

In the case where a state is publicly releasing its mortality data, but the CDC data was found to be more robust, we have also opted to use the CDC data. This is the case for the following states: Florida, Indiana, Iowa, Kansas, Kentucky, Missouri, Montana, Nevada, Oklahoma, Pennsylvania, South Carolina and Texas, as well as the balance of New York outside of New York City (which is reported separately). The result is the most comprehensive and up-to-date portrait of COVID-19 mortality by race and ethnicity for the U.S.

Racial detail on Americans who have died of COVID-19 was available for 96% of all deaths to date-a vast improvement from the 38% that were known when our Color of Coronavirus project began tracking these data in early April.

As of Tuesday, Nov. 10, more than 240,000 Americans had died of COVID-19. Data about race and ethnicity is available for 96% of these deaths.

However, it should be noted that even among states releasing COVID-19 data by the race of the deceased, the data is often incomplete or nonuniform. Numerous states release only percentages, not counts of deaths, requiring us to estimate the data rather than know precisely how communities have been affected. Many states also fail to report smaller populations uniquely, obscuring the picture for Indigenous Americans, Pacific Islanders and other groups. All of these reporting shortcomings render our picture of the virus' toll incomplete and make it more difficult to assess the disproportionate impacts on communities.
We call on state and local health departments to release timely data about COVID-19 deaths with as complete racial and ethnic detail as is possible. As the data reporting improves, so too will our understanding of the devastating impact of this disease. This will inform states and communities about how to direct resources more equitably as well.

SOURCES

State and local health department or other governmental reporting bodies, and the National Center for Health Statistics. In a few cases, we have upwardly revised total counts of deaths (not by race) to conform with the New York Times' latest database. Estimates from the U.S. Census Bureau's 2018 American Community Survey were used for calculations regarding population by race/ethnicity and age. Importantly, we have aligned population data with each geography's method of collecting and reporting data (i.e., if Latino ethnicity is overlapping with race groups or discrete, and whether race groups are reported "alone" or "alone or in combination"). All calculations and subsequent analysis by APM Research Lab.

NOTES

Deaths of unknown race are excluded prior to calculating percentages and rates. Presumed or probable deaths due to COVID-19 are included here in our death counts. Many of the data sources have labeled their data preliminary. In some cases, percentages will differ from those given by health departments due to our method of excluding deaths with an unknown race from the denominator before calculating percentages. Additionally states employ varying collection methods regarding ethnicity data, which results in percentages summing to more than 100%. Where states have reported only percentages, we have estimated deaths by racial subgroups; these deaths may differ by small amounts from actual due to rounding errors. States can improve this reporting by releasing complete data.
Data for Indigenous, Native Hawaiian and Other Pacific Islanders, and other races are tallied separately in some states, but exist in "other" in other states, due to inconsistent reporting among states.

Mortality rates are presented in two ways on this page: 1) As "crude" rates, meaning no adjustment has been made to standardize varying age distributions in the populations. These are labeled "actual mortality rates," as they reflect the actual death rates experienced in the population groups. 2) As indirectly age-adjusted mortality rates. Because the White population is older on balance in nearly all locations, age-adjusting generally widens disparities between Whites and other populations.
To create our age-adjusted death rates by race and ethnicity, we first calculated an "expected" death rate for each race group by state and the nation overall. We did so by multiplying the latest national age-specific death rates from COVID-19 by age-specific population shares for each race group within each of the geographies (sourced from the 2018 American Community Survey). We then divided the crude death rates for each race and geography by the expected race-based death rate we calculated (resulting in Standard Mortality Ratios), and finally multiplied by the nationwide overall crude death rate. The result is an Indirect Adjusted Death Rate (IADR) of COVID-19 by race.

We indirectly adjusted these data for age because direct age-adjustment was not possible; timely and complete COVID-19 mortality data by race and age group is not being released for all or even most states. However, users are cautioned that indirect standardization is done to approximate the impact resulting from varying age distributions in cases because age-specific death rates are not available. Indirect standardization may deviate more from directly age-adjusted rates when comparing two populations that differ significantly in their age distribution, as race groups may. For this reason, data from individual states that are directly age-adjusted should be considered superior. For more on direct and indirect methods of standardization see this CDC publication.

Thoughts? Questions?

We want to hear from you! Leave us a message below.

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COVID-19 deaths analyzed by race and ethnicity - APM Research Lab

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COVID-19 has claimed more than 240,000 lives in the U.S. This page documents and analyzes all racial and ethnic background data for COVID-19 deaths by state and the nation-especially to track the disproportionate mortality impacts of the coronavirus for Black, Latino, Indigenous and other Americans

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26. The cost of anti-Asian racism during the COVID-19 pandemic

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26. The cost of anti-Asian racism during the COVID-19 pandemic

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Main

Scholars have long documented patterns of labour discrimination against people of colour in the United States1,2,3,4,5,6. These forms of discrimination have substantial negative effects on communities of colour, denying social mobility to historically marginalized groups7,8. Even as some forms of discrimination have decreased over the recent decades9, racial discrimination in labour markets remains stubbornly persistent10,11. In this Article, we examine a closely related but much less studied economic phenomenon-consumer discrimination against businesses, especially small businesses associated with Asian Americans, during the COVID-19 pandemic.

Historically, marginalized groups have responded to the challenges of labour discrimination by starting their own businesses providing unique goods and services. Many Asian immigrants to the United States achieved economic success using this model by starting businesses such as laundromats and ethnic restaurants12. In the late nineteenth century, the United States heavily encouraged Asian immigration to supply cheap labour for manufacturing their burgeoning railroad system13. These immigrants founded America's first Chinese restaurants. By the early twentieth century, both hostility towards Chinese immigrants and Americans' appetite for Americanized Chinese food had increased substantially12. The 1970s saw a further resurgence of American interest in 'authentic' Chinese food12. Although restaurant entrepreneurship remains a pathway to economic success for Asian Americans, discrimination by consumers can negatively impact the efficacy of this pathway, especially during periods of heightened anti-Asian sentiment.

Marginalization, stigmatization and even violence towards minority groups has been a frequent historical response to public health14, terrorism15 and economic16 events. Although public blame (that is, rhetoric from politicians and mainstream media) is typically directed towards a singular foreign group, domestic hate crimes in response to these events often scapegoat American minorities and related groups that are mistakenly targeted. Tragically, Balbir Singh Sodhi, a Sikh American, was murdered after being mistaken for Arab Muslim in the aftermath of the 9/11 attacks, and Vincent Jen Chin, a Chinese American, was murdered after being mistaken for Japanese amidst rising blue-collar unemployment and American-Japanese economic competition in the early 1980s. Research on out-group homogeneity bias17 suggested that people tend to view out-group members as more similar to one another, as opposed to in-group members. Adding to this bias, scholars have identified a cross-race effect-the tendency to recognize faces that belong to one's own racial group while having difficulty differentiating members of the cross-racial group18,19. Furthermore, individuals with less cross-race exposure are more likely to have prejudicial attitudes towards other groups20,21. Finally, Asian Americans have historically been subject to the perpetual foreigner stereotype-the perception that naturalized or even native-born Americans of Asian descent are foreign or un-American. Taken together, these effects can allow prejudicial attitudes towards an out-group (Chinese, in our case) to drive prejudicial actions directed towards US domestic minority groups such as Asian Americans.

Here we examine the role of consumer discrimination against Asian businesses in the United States in the context of the COVID-19 pandemic. Previous studies have found that consumer discrimination substantially decreases small-business ownership and self-employment among people of colour in the United States25,26,27,28, as does discrimination by funding sources29. Among small businesses, consumer discrimination is especially salient for restaurants that specialize in ethnic cuisines, as the food's ethnic origin is a key aspect of product differentiation. Although restaurant entrepreneurship remains a pathway to economic success for Asian Americans, discrimination by consumers can negatively affect the efficacy of this pathway, especially during periods of heightened anti-Asian sentiment. We leverage the COVID-19 pandemic as an exogenous shock to rhetoric and attitudes about Asian Americans in the United States. Soon after COVID-19 began spreading in the United States, then-President Trump and the Republican Party began a concerted effort to blame China for the virus. Political and media figures used the phrases 'China virus' and 'Kung Flu' to describe the coronavirus, in contradiction to World Health Organization (WHO) guidance30 and previous research demonstrating how disease naming can lead to stigmatization, particularly of marginalized and minority groups. The effects of this rhetoric did not go unnoticed-the number of anti-Asian hate crimes spiked during the pandemic33,34, impacting both Chinese Americans and the broader Asian American community. Self-reports35,36 and surveys37 from Asian American citizens and business owners have suggested that the community has seen disproportionate, negative impacts during the pandemic.

Innuendos of 'uncleanness' and disease have long been used to stigmatize marginalized populations and justify their expulsion. From blaming European Jews for the bubonic plague in the Middle Ages38 to claiming that immigrants crossing the southern border of the United States are 'diseased'39, majority groups have long misattributed blame for diseases to 'undesirable' minority populations. In the United States, the portrayal of immigrants as dangerous and diseased shaped immigration policy for decades40,41. Modern-day attitudes towards disease threat are closely related to anti-immigration attitudes42,43. This carries forward into the present with rhetoric falsely trying to tie the fourth wave of COVID-19 illness to undocumented immigrants coming through the US southern border44.

These stigmas have been especially prevalent in the treatment of Asian Americans in the nineteenth and twentieth centuries. Medical examinations of Chinese immigrants arriving at Angel Island were frequently harsher than those of Europeans at Ellis Island, and the rejection rate for Chinese immigrants was at least five times higher than for European immigrants at Ellis island41. These attitudes extended towards Asian cultural products in the United States, especially Chinese food. Although early Chinese restaurants founded in San Francisco during the California Gold Rush were praised as tasty and economical, the rising tide of Sinophobia soon led to rumours of the consumption of rats and snakes as Chinese delicacies, leading to a decrease in the popularity of Chinese restaurants12. More recently, the popularization of the term 'Chinese restaurant syndrome', based in medically unfounded fears over the effects of monosodium glutamate45,46, is another example of cultural discrimination against Chinese restaurants.

Portrayals of the COVID-19 crisis echoed many of these historical patterns of negative attitudes and discrimination against this group in the face of public health concerns. The SARS-CoV-2 virus was regularly referred to as the 'Chinese virus' or 'China virus', both offline47 and online. Donald Trump and Trump-supporting Republicans and media began to refer to COVID-19 as the 'China virus' and explicitly blame the pandemic on China despite consistent criticism from Asian Americans and left-leaning media outlets. Between 16 March 2020 and 3 Jan 2021, Trump used the phrase 'China virus' or 'Chinese virus' in 54 separate tweets. This explicit blame on China by the politicians was then reinforced and further spread into the mainstream media outlets that rebroadcast this rhetoric. Recent research has demonstrated how social media also has a vital role in building and reproducing negative sentiment against marginalized groups. For example, recent studies have examined the spread of anti-Muslim sentiment through hashtags on Twitter51,52. Similarly, two studies to date have demonstrated the link between hashtags that used the language of this rhetoric (for example, #Chinesevirus) and anti-Asian sentiments on Twitter50,53. Although establishing a causal relationship between the political rhetoric and anti-Asian sentiment is beyond the scope of our current research, this suggests the possibility that anti-Asian sentiment initiated by the political figures may have spread broadly and quickly on both mainstream media and social media.

Against this backdrop, recent research adds to the growing evidence that Asian Americans were blamed for the COVID-19 pandemic. For example, fear of COVID-19 is highly correlated with anti-Asian attitudes and support for anti-Asian immigration policies in the United States54. Furthermore, an experimental study has shown that emphasizing the origin of COVID-19 to China increased anti-Asian sentiment and xenophobia55. Following this logic, we argue that the COVID-19 pandemic served as an exogenous shock-an unpredictable event from outside the economic system, such as a war, natural disaster, global pandemic or new technology, that affects economic behaviour-that gave voice to politicians who were increasingly making explicitly racial appeals by singling out marginalized groups56, thereby contributing to the increase in anti-Asian attitudes within the United States.

Drawing from the psychological theory of blame, we put forth the idea that, not only was the country of origin directly blamed for the pandemic, but also other groups that are often mislabelled as Chinese subsequently became the targets of collective blame. Alicke's model of culpable control57 suggests that blame is the outcome of psychological processes driven by cognitive and motivational biases, which may be independent of a party's actual liability. Furthermore, his theory posits that people may assign blame on the basis of the proximity criteria. To the extent that the associated party is viewed as sufficiently proximate to the party that is presumed to be guilty, it is possible that even the group (that is, businesses owned by Chinese Americans) that is not blamed for the harm may still be cognitively implicated. Although there were legitimate questions about whether or not food could carry COVID-19 in the early days of the pandemic, this concern alone would not be sufficient if some restaurants were disproportionately affected by the COVID-19 pandemic compared with others, as there was not a legitimate concern about any particular type of food. Facing COVID-19 as an exogenous shock and the anti-Asian rhetoric and attitudes that followed, we hypothesize the following.

H1: during the COVID-19 crisis, Chinese restaurants will see a substantial decrease in visits relative to non-Asian restaurants. Much of the consumer research on blame spillover has been documented in the context of brands that were implicated in moral transgressions. This effect was found to be more prominent to the brands that consumers identify as similar to the brand that was implicated in ethical scandal. On the basis of this literature, we further argue that how consumers ascribe blame on the associated groups may contribute to the struggles of other Asian restaurants that are not Chinese. This blame spillover may occur through two channels. First, it is possible that non-Chinese entities were incorrectly identified as Chinese, thereby being erroneously blamed for the pandemic. Second, it is also plausible that non-Chinese entities were correctly identified (which we call the 'ethnic misidentification hypothesis', described below), but viewed as a proximate entity under the broader umbrella of Asian race and ethnicity, thereby being categorically avoided. Both possibilities support the idea that other Asian restaurants will be negatively affected at the early onset of COVID-19 in the United States, leading to our second hypothesis:

H2: after COVID-19, non-Chinese Asian restaurants will also experience a substantial drop in visits relative to non-Asian restaurants. Notably, these portrayals were not spread evenly across the population-Republican-leaning news outlets, such as Fox News, were more likely to blame China for the pandemic compared with other outlets63. Owing to the prevalence of these narratives among Republican politicians and news sources, we argue that this shock was not homogeneously distributed throughout the population. Scholars have long noted that partisans in the United States tend to follow opinion cues provided by leaders of their political party. Partisans are much more likely to follow suggestions and absorb information when it is presented to them by leaders in their own party, as compared to non-partisan figures and especially figures from the opposing party. This partisan-cuing effect extends to a variety of topics, including vaccination67, mask wearing68 and COVID-19 blame attribution69. This suggests that Republicans, whose party leaders and media outlets engaged in anti-Asian-cuing behaviour, should be more likely to respond with consumer discrimination against Chinese and Asian restaurants, leading to hypothesis 3.

H3: areas with greater support for Trump would see a larger relative decrease in visits to Chinese restaurants compared with areas with lower support for Trump. Finally, we propose a potential mechanism for spillovers to non-Chinese Asian restaurants (such as 'Tiger Belly Noodle Bar') of which the names are ethnically ambiguous but could potentially be classified as Chinese. During the pandemic, anti-China rhetoric often invoked prejudice and stereotypes such as the eating of bats or snakes70 and martial arts71, which, while targeted at China, are common stereotypes of East Asians as a whole. Politicians' use of these stereotypes could both activate in-group favouritism and be indicative of the prevalence of these out-group stereotypes among their constituents. In either case, an activation of group membership has been shown to change how individuals process and perceive information about the out-group members, with the potential to increase perceived out-group homogeneity. We therefore predict that Trump voters who are more exposed to anti-China rhetoric from Republican-leaning news outlets will exhibit decreased differentiation between Asian ethnic groups and thereby increased chances of misidentification. This yields our final hypothesis.

H4: Trump voters would be more likely to misidentify non-Chinese Asian restaurants compared with non-Trump voters. We present empirical results that test these hypotheses within consumer mobility data by comparing pre- and post-pandemic consumption behaviour, supplementing our analysis with search data and a series of surveys to describe linkages between political rhetoric, consumer sentiment, search and subsequent consumer traffic behaviour ( Methods). We found clear evidence of sharp attitudinal shifts against China, Chinese Americans and Asian Americans as a whole during the COVID-19 pandemic. These shifts have the potential to create economic harm for Asian American communities, as people who have internalized this rhetoric look to avoid products affiliated or associated with China. Furthermore, Americans tend to stereotype Asian Americans as foreign, consistently overestimate the fraction of Asian Americans who are ethnically Chinese, and have difficulty differentiating between Chinese Americans and other Asian Americans, putting the broad Asian American community at risk from anti-Chinese sentiment and behaviour. Consistent with our hypotheses, we document and quantify the disproportionate decrease in business for both Chinese and other non-Chinese Asian restaurants during the COVID-19 crisis, suggesting that the increase in anti-China sentiment incurred not only a social cost, but also a real economic cost to the Asian American community.

Results

Using web search, survey and movement data, we documented and quantified the impact of anti-China sentiment on both Chinese Americans and the spillover effects on other Asian American populations. First, we used web search data to demonstrate the exogenous shock of the COVID-19 pandemic on American conceptions of China and Chinese food. Next, movement data enabled us to measure the effect of anti-Asian attitudinal shifts on consumer discrimination against both Chinese and other Asian restaurants, quantifying the economic effect of anti-Chinese rhetoric on Asian American communities. Finally, we used survey data to examine different underlying mechanisms that may influence these shifts.

Web searches confirm a pandemic spike in anti-Chinese sentiment

Our analysis first established the temporal relationship between the COVID-19 pandemic and anti-Asian attitudes. We expect that searches that tie COVID-19 to China would spike during the pandemic (that is, a search for 'China virus' would not necessarily tell us anything about the searcher's attitudes), whereas searches for something like 'China owns us' would be more indicative of anti-Asian attitudes, as they have no clear relationship to the pandemic. Confirming this, all three categories of non-COVID-related anti-China searches (that is, searches relating to China and Communism (political), searches relating to China and debt (economic), and searches relating to explicit anti-China phrases (social/stereotypical)) are related to negative attitudes towards China and stereotypes about Chinese people and culture that predate the pandemic (Fig. 1a). Our results suggest that search patterns in 2020 looked very different from those in the four previous years. In the case of Communism searches, we saw a slightly subtler effect, whereby the overall number of searches for China and Communism was substantially higher throughout the year, beginning in mid-March. For searches around debt and explicit anti-China searches, we saw a sharp discontinuity at the week of 11 March 2020 that was not present in any of the previous years, despite the United States starting a well-covered trade war with China in 2019.

a, Google Trends shows sharp increases in negative searches relating to China during the week of 11 March 2020. The vertical dashed line represents the Declaration of National Emergency issued by former US President Donald Trump on 13 March 2020. There were no similar increases in these searches during the same time period in 2016-2019. b, Google Trends shows sharp increases in searches relating to Chinese people eating bats and dogs during the week of 11 March 2020. There were no similar increases in these searches during the same time period in 2016-2019. There is a substantial correlation between searches for eating bats and eating dogs, despite the fact that the dog-eating stereotype has no relevance to the COVID-19 pandemic.

Specifically, we also compared searches for Chinese consumption of bats versus consumption of dogs. Search interest in Chinese bat consumption was probably driven by media coverage, but consumption of dogs has no relationship to the pandemic and did not receive media coverage. As such, if we see an increase in searches for Chinese consumption of dogs, this is another possible indicator of affirming the negative stereotypes about China. Searches related to eating animals, presented in Fig. 1b, further underscore these results. Although there were clear, news-driven spikes for eating bats around the emergence of COVID-19 and again at the beginning of the pandemic in the United States, the relationship between searches for eating bats and eating dogs is very clear and distinct. Dog-eating behaviour had no relationship to the pandemic, but is closely related to anti-Chinese stereotypes. These search patterns show a sharp discontinuity in anti-Chinese sentiment during the COVID-19 pandemic. Next, we consider the impacts of this shift in sentiment on the livelihoods of Asian Americans in the United States.

Consumers avoid Asian restaurants during the pandemic

An analysis of consumer mobile device location data using a difference-in-difference framework indicates that consumers exhibited relative avoidance of Asian restaurants (Table 1). We found that, during the period after the onset of COVID-19, Asian restaurant traffic decreased by a substantial 18.4% (two-sided t-test, P < 0.001, 95% confidence interval (CI) = −15.9% to −20.8%) relative to non-Asian restaurant traffic during the same period and after controlling for COVID-19 case rates. Chinese restaurant traffic dropped 10.9% (two-sided t-test, P < 0.001, 95% CI = −8.4% to −13.3%), whereas non-Chinese Asian restaurant traffic saw a greater (two-sided Z-test for comparison of regression coefficients, P < 0.001, 95% CI = 12.6% to 22.0%) decrease of 25.0% (two-sided t-test P  < 0.001, 95% CI = −22.1% to −27.9%). These patterns support hypotheses 1 and 2, which predicted that both Chinese and non-Chinese Asian restaurants would experience substantial decreases in visits relative to other types of restaurants. The decrease in traffic represents a considerable loss of revenue for Asian restaurants, which we estimate through a combination of counterfactual simulation and a back-of-the-envelope calculation. Our calculation indicates that the relative consumer avoidance of Asian restaurants through the pandemic cost those restaurants US$7.42 billion in foregone revenue in 2020.

Table 1 Effects of the pandemic on Asian restaurant traffic

Greater Trump support is associated with a larger drop in Asian restaurant traffic

Given that former President Trump was a main source of anti-China rhetoric assigning pandemic blame to China, we look at whether greater support for Trump was associated with a larger relative drop in Chinese and, more broadly, Asian restaurant traffic in the post-pandemic period (hypothesis 3). For this analysis, we use Trump's 2016 vote share rather than his 2020 vote share, as his share in 2020 may have been affected by both regional variation in pandemic severity and perceptions of his management of the pandemic. As additional robustness, we also replicate these results using the 2018 election data ( Supplementary Information). We examined heterogeneity in Asian restaurant avoidance by repeating our main analysis at the ZIP-code level, calculating our difference-in-difference estimation of pandemic traffic impacts for (1) all Asian restaurants; (2) Chinese restaurants; and (3) non-Chinese Asian restaurants; the results are visualized in Fig. 2, and interaction regression results are reported in Table 2. The ZIP-code-level subsamples replicate our main effects, indicating persistent negative traffic impacts on Asian restaurants during the pandemic. Furthermore, there is a visible negative correlation between traffic impact and Trump's 2016 vote share at the ZIP-code level (Fig. 2). This visual pattern was confirmed by a regression test: Trump's 2016 vote share is a significant predictor of negative traffic impact (consumer avoidance) for each of Asian (two-sided t-test, P < 0.001, 95% CI = −0.036 to −0.080), Chinese (two-sided t-test, P < 0.001, 95% CI = −0.027 to −0.075) and non-Chinese Asian (two-sided t-test, P < 0.001, 95% CI = −0.056 to −0.110) restaurants as shown in Table 2, which regresses the coefficient of avoidance at the ZIP-code level on each ZIP code's voting share in 2016. Finally, while the average coefficients estimated in Table 1 showed greater avoidance of non-Chinese Asian restaurants compared with Chinese restaurants, we observe in Fig. 2 that this trend reverses for ZIP codes with high Trump support. This provides support for hypothesis 3-that greater Trump support would be associated with greater avoidance of Chinese restaurants.

ZIP-code-level impact to Asian, Chinese and non-Chinese Asian restaurants by Trump vote share in 2016. Impact coefficients were calculated for each ZIP code using the difference-in-difference method using the specification in equation ( 1) relative to non-Asian restaurants within the ZIP code. The grey shaded region displays the 95% CI of the mean impact coefficient (blue line) of ZIP codes with the given level of Trump support, visualized using LOESS smoothing with span = 0.5. These plots indicate that the Trump vote share in 2016 correlates with greater avoidance of Asian, Chinese and non-Chinese Asian restaurants in the post-pandemic period.
Source data

Table 2 Heterogeneity in effects

Evidence for consumer discrimination

Consumers blame pandemic spread on Asians and express fear of Chinese food

We assessed consumer blame for pandemic spread by asking American respondents a straightforward question: 'Which racial or ethnic group do you believe is most responsible for bringing COVID-19 (also known as coronavirus) into the US (if any)?' This survey on consumer blame was run in four waves throughout the pandemic, and, for the first three waves, we had one iteration of the question with six possible answers presented in a randomized order: 'Asians', 'Blacks', 'Latinos', 'Whites', 'No racial or ethnic group is responsible' and 'Don't know'. We would expect that, if anything, social desirability would motivate people to over-respond 'no racial or ethnic group is responsible', but that answer hovers in the low 60s, with a meaningful (but monotonically decreasing) 27% (wave 1) to 17% (wave 4) reporting that Asians, the most commonly blamed ethnic group, are the most responsible for pandemic spread. In wave 4 on 15 April 2021, we randomly assigned half of the sample to see a different set of answers to the same question, again in a randomized order: 'Chinese', 'Japanese', 'Italian', 'French', 'Mexican', 'Greek', 'Indian', 'Thai', 'other', 'no racial or ethnic group is responsible' and 'don't know'. Even at this late date, 38% answered that Chinese people are the most responsible for pandemic spread. Although 'no racial or ethnic group is responsible' was the most popular answer under all of the answer sets and days, a non-negligible number of Americans blame Asian, and Chinese in-particular, individuals for bringing COVID-19 into the United States. These results are visualized in Fig. 3a.

a, b, The survey participants were asked the indicated questions on blame ( a) and fear ( b). For a, when the answer was 'Asians', the full set of other options included: 'Blacks', 'Latinos', 'Whites', 'No racial or ethnic group is responsible' and 'Don't know'. When the answer was 'Chinese' the full set of other options included: 'Japanese', 'Italian', 'French', 'Mexican', 'Greek', 'Indian', 'Thai', 'Other', 'no racial or ethnic group is responsible' and 'don't know'. The four waves have the following raw demographics-wave 1, 5 May 2020 (57% female; mean age, 43 years; age s.d. 16 years); wave 2, 27 August 2020 (55% female; mean age, 42 years; age s.d., 15 years); wave 3, 29 October 2020 (57% female; mean age, 38 years; age s.d., 13 years); wave 4, 15 April 2021 (49% female; mean age, 39 years; age s.d., 11 years)-but were raked to represent US demographics.

Trump voters blamed Asians, in particular Chinese, at much higher rates compared with Biden voters for the spread of the pandemic. In the final survey on 15 April 2021, just 12% of Biden voters said that they blame Asian people, with 32% blaming Chinese people (Fig. 3a). However, in the same survey, 27% of Trump voters blamed Asian people (mean difference, +14 percentage points (pp) versus Biden voters, two-sided Z-test, P < 0.001, 95% CI = +4.4 pp to +23.8 pp), and a majority (56%), blamed Chinese people (mean difference +24 pp versus Biden voters, two-sided Z-test, P  < 0.001, 95% CI = +14.2 pp to +33.7 pp).

We also asked a direct question about fear and risk of contracting COVID-19: 'When considering delivery food, ordering which (if any) of the following types of food do you believe presents an increased risk of contracting COVID-19 (also known as coronavirus) into the US (if any)?' This question allowed for multiple answers, and 'Chinese food' was very consistently the leading answer with between 15% and 22% (Fig. 3b). This was between 5 and 9 pp higher than the next answer. Notably, Biden and Trump voters exhibited a small gap in response to this fear question (22% versus 25%, respectively), whereas our restaurant-traffic analysis indicated that avoidance of Chinese and more broadly Asian restaurants is strongly and significantly correlated with support for Trump. This suggests that blame sentiment may have had a larger role in restaurant avoidance than fear of contracting COVID-19 from Chinese food.

Finally, we examined the interaction between perceptions of Asian homogeneity and directed blame or fear, as shown in Fig. 4. We asked respondents 'What fraction of Asians in the US do you think are ethnically Chinese?' We noted two trends: first, respondents consistently overestimated the fraction of Asians Americans who are Chinese (mean survey response, 35% versus 24% actual75). This is consistent with the predictions of out-group homogeneity bias, whereby respondents will tend to overestimate the homogeneity of the out-group. Second, examining respondents who believed that a majority (50% or more) of Asians in the United States were ethnically Chinese, we found that this group is also significantly more likely to believe that Chinese food represented an increased risk of contracting COVID-19 (27% versus 16% among respondents who did not think the majority of Asians are ethnically Chinese; mean difference, +11 pp, two-sided Z-test, P < 0.001, 95% CI = +7.0 pp to +14.9 pp) or that Asians were to blame for the spread of COVID-19 (28% versus 23% among respondents who did not think that the majority of Asians are ethnically Chinese; mean difference, +5 pp, P  = 0.020, 95% CI = +0.0 pp to +9.6 pp). This second trend supports the relationship between the perceived homogeneity of Asians as a group and fear and blame directed towards Asian American individuals.

Responses to questions on fear and blame broken down by the perceived percentage of Asian Americans who are ethnically Chinese from waves 1 and 2 of the survey (5 May 2020 and 27 August 2020, respectively). Respondents who perceive that more Asian Americans are Chinese were also more likely to blame Asians for the spread of COVID-19 in the United States and believed that Chinese food posed an increased risk of contracting COVID-19.

Searches relating to Chinese food safety increased

To further investigate the question of fear versus discrimination, we examined the search patterns around Chinese restaurants and other restaurants from 2016 to 2020. Figure 5 shows that searchers exhibited very different search patterns around Chinese restaurants. For regular searches around restaurant safety, we see a large spike in the week immediately after Trump's 11 March 2020 address. However, for searches relating to the safety of Chinese food, the largest spikes came in February and early March 2020, with the largest spike during the week of 11 March 2020. These results again support hypothesis 1 and show that people were thinking about the safety of Chinese restaurants and other restaurants differently during the pandemic.

The vertical dashed line represents the Declaration of National Emergency issued by former US President Donald Trump on 13 March 2020. Google Trends data show that searches relating to concern about the safety of Chinese food peaked earlier compared with searches relating to concerns about the safety of restaurants in general.

Misidentification as a spillover mechanism into non-Chinese Asian restaurants

Following on from our mobility analysis, we investigated the potential for anti-China messaging spillovers to create a decrease in business for non-Chinese Asian restaurants. We specifically examined confusion among Asian restaurants as a potential mechanism, motivated by extant literature on out-group homogeneity bias and a history of attacks against Asian Americans in cases in which attackers were motivated by hatred against one Asian group yet attacked victims of another Asian group76,77. In a separate survey with 2,345 participants, each participant was shown a list of 20 ethnic restaurant names (selected from Chinese, Japanese, Korean, Thai, Vietnamese, Indian, Mexican, Italian and French), randomly selected from real, mono-ethnic restaurants within the SafeGraph location dataset, and we asked the participants to categorize each one by its ethnicity. We found that misidentification is high: 33% of Asian restaurants are incorrectly labelled by respondents. The most commonly mislabelled Asian restaurants were Korean and Vietnamese, which were incorrectly labelled 52% and 47% of the time, respectively. Both of these were most commonly mislabelled as being Chinese, consistent with a misclassification mechanism behind Asian restaurant avoidance.

We also broke down the correct response rate by participants' 2016 and 2020 voting preferences, as shown in Fig. 6. These results indicate that Trump 2016 and 2020 voters were more likely to misidentify Asian restaurants (36.4% and 35.2% misidentification, respectively) compared with Clinton 2016 and Biden 2020 voters (30.9% and 31.6% misidentification, respectively). Two-sided Z-tests for a difference in proportions comparing Trump versus Clinton voters in 2016 and Trump versus Biden voters in 2020 indicate that these differences in misidentification rate are highly significant ( P  < 0.001 for each), supporting hypothesis 4.

The misidentification rate of Asian restaurants split on the basis of voting preferences. An MTurk survey was conducted with 2,345 participants (51.3% female; mean age, 39.4 years; age s.d., 12.6 years), who were asked to label a randomly selected sample of real, mono-ethnic restaurants from the SafeGraph dataset by ethnic group. Trump voters in 2016 and 2020 exhibited 36.4% (95% CI = 35.3% to 37.4%) and 35.2% (95% CI = 34.1% to 36.3%) misidentification, respectively. Clinton 2016 and Biden 2020 voters exhibited 30.9% (95% CI = 30.1% to 31.7%) and 31.6% (95% CI = 31.0% to 32.3%), respectively. P values were calculated using two-sided Z-tests for difference in proportions.

Discussion

Our results support the role that the COVID-19 pandemic had in activating latent anti-Asian sentiment as expressed through consumer search, survey responses and foot-traffic behaviour. We found empirical support for each of our hypotheses, namely that both Chinese and non-Chinese Asian restaurants saw a drop in traffic during the pandemic, that areas with more Trump support saw a larger relative drop in Chinese restaurant traffic than those with lower Trump support, and that Trump voters were more likely to misidentify Asian restaurants compared with non-Trump voters.

A natural question that may arise from our analysis is the extent to which the observed changes in traffic may be driven by supply-side changes such as Asian restaurants independently deciding to limit operations versus demand-side changes such as consumer avoidance of Asian businesses. Although we cannot directly quantify this, we provide evidence that a mechanism by which our observed drop in traffic is purely driven by a reduction in Asian restaurant operations is improbable. Small business owners look to garner revenue to support themselves, their employees and cover fixed expenses such as rent, suggesting that a greater reduction in Asian restaurant operations relative to comparable non-Asian restaurants in the absence of changes in Asian restaurant demand would result in unnecessary economic losses for Asian restaurant owners. Other interviews and anecdotal reports78 from Asian American business owners also support that lack of demand is a key impediment. Furthermore, as illustrated in the survey analysis, a sizable fraction of consumers expressed blame towards Asians for pandemic spread and fear that consuming even takeaway Chinese food would present an increased risk of contracting COVID-19, reinforcing the major role of the shifting consumer demand for Asian food. A deeper examination of this question on the relative roles of supply and demand side explanations for the observed empirical patterns is a promising area for future research, although it is outside the scope of this study, which focuses on first quantifying the economic effects of the COVID-19 pandemic and the associated stigmatization on Asian American restaurants and the corresponding communities. Stigmatization and pandemic blame are underlying driving factors under both supply- and demand-side mechanisms that impact the economic livelihoods of Asian Americans.

Our finding that Chinese restaurant avoidance increased with Trump vote share suggests that the assignment of pandemic blame had downstream impacts on consumers' food-consumption choices. As a substantial fraction of Asian restaurants in the United States serve Chinese food, the finding that Asian restaurants as an average, overall group saw a decrease in traffic is unsurprising. What is less expected is that non-Chinese Asian restaurants saw a greater average decrease in traffic compared with Chinese restaurants at the nationwide level. In understanding this heterogeneity in effects between Chinese and non-Chinese Asian restaurants, we again look to Fig. 2 and observe that ZIP codes with very low levels of Trump support have less of a negative impact in traffic to Chinese restaurants relative to non-Asian restaurants in similar locations. Furthermore, the same figure shows that avoidance of Chinese restaurants is more sensitive to Trump support than avoidance of non-Chinese Asian restaurants. This is explored further and reinforced by the results of the three-way interaction model in the Supplementary Information. This probably reflects how anti-Chinese sentiment became politically polarized during the pandemic. Although former president Trump had used stigmatized language to refer to the pandemic, his political opponents such as then Speaker of the House Nancy Pelosi made efforts to explicitly support Chinatowns through the pandemic79. We also must recognize the community efforts of Asian American organizations, such as Welcome to Chinatown, Send Chinatown Love and Think!Chinatown, among many more through the pandemic to support Chinatowns, Chinese American restaurants and Asian American businesses more broadly. Moreover, mainstream press coverage78,80,81,82,83 tended to focus on how Chinese American businesses and Chinatowns struggled through the pandemic, which, in combination with the community support organizations described, probably led sympathetic consumers to specifically identify and support Chinese restaurants during this period. Asian American advocacy groups and efforts tend to be centred around urban areas and more liberal-leaning population centres, which shows up in our data as lower avoidance in areas with low Trump support and affects our observed patterns on average avoidance of Chinese versus non-Chinese Asian restaurants nationwide.

By contrast, we observed an inflection point when Trump support crosses around 65% and avoidance of Chinese restaurants is greater than avoidance of non-Chinese Asian restaurants. This is consistent with our survey results in the previous section, which indicate correlations between political affiliation, pandemic blame towards Asian Americans, increased perceptions of risk from Chinese and Japanese food, and indications of outgroup homogeneity (such as overestimating the proportion of Asian Americans that are Chinese). In the locations in which our surveys predict the greatest stigma against Asians, Asian Americans and Chinese food, we do see greater avoidance of Chinese restaurants compared with non-Chinese Asian restaurants, and these levels of avoidance are very high compared with comparable non-Asian restaurants in these areas. For these reasons, we believe that the patterns of observed heterogeneity reinforce rather than diminish the role of political racial stigma in driving restaurant consumption.

Recalling our other survey result in Fig. 4, we noted a significant interaction in that respondents who (falsely) believed that a majority of Asians in the United States were Chinese were also more likely to report a fear that Chinese food represented an increased risk of contracting COVID-19. We also found that greater Trump support is associated with both increased misclassification of Asian restaurants and greater avoidance of non-Chinese Asian restaurants (Fig. 2). Taken together, these results illustrate the linkage between expressions of out-group homogeneity bias (perceived increased homophily or inability to distinguish between out-groups) and Asian restaurant avoidance attitudes and behaviours. These patterns are all highly consistent with a mechanism whereby non-Chinese Asian restaurant avoidance is influenced by ethnic misidentification as stated in hypothesis 4. However, we caution that this does not constitute a causal test of the role of ethnic misidentification or enable us to disentangle the relative roles of misidentification and alternative mechanisms such as collective blame that are also correlated with out-group homogeneity.

Finally, a comparison of pandemic blame and food fear survey results suggests that food safety concerns were probably not the determining factor behind the disproportionate drop in visits for Chinese and non-Chinese Asian restaurants among Trump supporters. Trump voters were relatively comparable to Biden voters in expressing safety concerns with consumption of Chinese food (25% versus 21%, respectively), yet Trump voters were approximately twice as likely to attribute blame for pandemic spread to Asians (27% versus 12%) or Chinese (56% versus 32%).

In summary, the patterns that emerge are consistent with our theories on the role of collective blame and outgroup homogeneity in driving consumer avoidance of Chinese American restaurants and the spillovers to even non-Chinese Asian American restaurants. Here we highlight again that a majority (56%) of Trump voters in our 15 April 2021 survey blamed Chinese people for the spread of the pandemic and, in the between-participants design, approximately half as many Trump voters (27%) blamed Asians as a whole. At the time of the survey, COVID-19 cases had fallen considerably from their peak at the beginning of 2021, and yet blame levels remained comparatively robust. Survey respondents on average overestimated the fraction of Asian Americans who are ethnically Chinese, and individual respondents who greatly overestimated the fraction were also significantly more likely express that Asians were to blame for the pandemic or that Chinese food represented an increased risk of contracting COVID-19. The notion of collective blame holds that feelings of blame extend from individuals or subgroups to the collective whole, and that one's willingness to do so depends on the ability to see out-groups as a homogeneous, monolithic entity. The perception of division between in-group and out-group membership can both reinforce and be reinforced by stereotypes84, as probably occurred through then-President Trump calling COVID-19 'Kung Flu', which tied elements of Chinese and more broadly Asian cultural heritage, persistent stereotypes of Asian Americans85 and the chaotic beginnings of a global pandemic.

Contributions

Our contributions are three-fold. First, we examined the role of racially salient events in shaping levels of consumer discrimination against businesses. The accessibility of race as a dominant category for in-group and out-group distinction has been shown to influence various outcomes for the minoritized groups, ranging from housing discrimination against Arab Americans86 to evaluative bias and discrimination against African American job applicants and entrepreneurs87,88. Our research establishes the pandemic-driven blaming of Asians as one instantiation of mega-threats, referring to negative, identity-relevant societal events that receive significant media attention89 in the context of entrepreneurship and consumers. Entrepreneurship has historically served as a viable exit strategy for populations facing labour discrimination. However, for businesses serving customers outside their ethnic community of origin, consumer discrimination can hamper the economic viability businesses. If levels of consumer discrimination fluctuate based on current events, otherwise-profitable businesses may quickly become unviable during periods of high discrimination and violence. Furthermore, unpredictability of demand for the businesses' products may also serve as a barrier to entry for potential entrepreneurs.

Although our results focus on consumer discrimination against Asian restaurants in the wake of the pandemic, these findings have relevance in a much broader context. Restaurants are a bellwether for broader anti-minority-group sentiment and its impact on small businesses owing to their ubiquity and easy association with an ethnic group. Other small businesses, such as dental offices, lawyers, doctors and accountants, are also easily affiliated with an ethnic group due to typical naming conventions, and our conclusions on how restaurant avoidance is not explained by consumer health safety concerns have substantial implications for consumer discrimination against these businesses as well. There are numerous historical examples of anti-ethnic sentiment due to major geopolitical events, including anti-Arab/Islam and anti-French (Freedom Fries) sentiment in the aftermath of the 9/11 attacks and anti-Japanese sentiment amidst rising American-Japanese competition in the 1980s. However, despite numerous reports of attacks on minorities and anecdotal reports of consumer discrimination, there are considerable difficulties with quantifying the impacts that these crises had on minority-group-owned businesses. The recent pandemic has coincided with major technological advances in location data availability, enabling a granular, quantitative analysis of the impacts on small businesses and misidentification-related spillovers, which were not possible during previous crises.

Second, our research uncovers consequences that may have gone unnoticed. Recent research has documented the rise of racial discrimination and prejudice against Asians and Asian Americans, which resulted in poorer mental and physical health90 and marginalization91 in these groups. Other studies on anti-Asian discrimination during the pandemic have relied heavily on data from self-reported incidents of hate against Asian Americans35 and police statistics92 on violent attacks; by contrast, our study examines more subtle social and economic impacts of discrimination that are highly relevant to the lives of Asian Americans yet might not rise directly to the level of hate or violence. This study avoids the selection biases of self-reporting or police reporting, whereby immigrant groups may be hesitant to contact authorities93, and it uses a big-data approach to the question of discrimination covering hundreds of billions of trips to six million locations throughout the United States in comparison to the approximately 9,000 self-reported hate incidents and only 279 hate crimes identified by the FBI against Asian Americans in 2020.

Finally, our study contributes to the psychological theories of collective blame by highlighting the role of ethnic misclassification in consumer discrimination. By examining the costs incurred by both Chinese and non-Chinese Asian restaurants, we capture the process of blame spillover from businesses associated with one ethnic group to the larger tangentially related populations. This spillover effect, at least partly fuelled by the 'yellow peril' stereotype for Asians in general34 lends support to the theory of collective blame that arises from out-group homogeneity bias and cross-race effects. Our study of consumer discrimination demonstrates these spillover effects through ethnic misclassification in an ecologically valid setting. For example, cross-race effects have been found in people's perception of out-group members' faces. Our research extends this line of work by showing that a similar pattern occurs for consumer perception of out-group-owned businesses as well. Studying consumer discrimination based in ethnic and racial misclassification also advances our understanding of the experiences of individuals and entities that are regularly misclassified. For example, research on racial misclassification97 identified the negative psychological consequences for American Indians who were often misclassified as a different racial group. Our research stresses the prominence of a similar mechanism for Asians who are not ethnically Chinese, and broadens it to encompass social and economic costs.

Limitations

A number of limitations of this research derive from the fact that the onset of COVID-19 was a single, unprecedented shock to public health and the global economy. As previously highlighted, we were unable in the present data to directly quantify the relative roles of supply versus demand side explanations for the observed drops in traffic, although we offer evidence that a purely supply-driven mechanism is unlikely. Moreover, we cannot entirely disentangle the relative role of political leaders' anti-Asian rhetoric from endogenous anti-Asian sentiment arising from the public health threat itself. History has repeatedly shown that blaming marginalized groups for public health crises is sadly quite common31,32. For example, Irish immigrants were blamed as the bearers of cholera, and Jewish immigrants were blamed for tuberculosis98. More recently, African and Chinese cultural habits were also blamed for the outbreaks of Ebola and SARS99, and Latino individuals were blamed for the spread of H1N114. It is possible that anti-Asian sentiment would have arisen even in the absence of statements by public officials targeting Asians. Alternatively, politicians' statements stigmatizing the pandemic could be a reflection of constituents' pre-existing beliefs rather than formative of those beliefs. Although we cannot reliably create a counterfactual world in which COVID-19 was not followed by anti-China rhetoric by the US political leaders, this is a ripe area for future research to further examine the relative importance of different triggers for anti-Asian sentiment, discrimination and behaviour.

Conclusion

Here we examined the effects of anti-Asian sentiment on consumer discrimination against restaurants associated with Asian Americans. Leveraging and documenting the COVID-19 pandemic as an exogenous shock to anti-Asian sentiment, we found a marked and substantial decrease in visits to both Chinese and non-Chinese Asian restaurants. Consistent with partisan-cuing theories, we found that this effect is most prominent in areas with more Trump voters. Although Trump voters were not more likely to express safety concerns with consumption of Chinese food, they were significantly more likely to attribute blame for pandemic spread to Asian or Chinese people. This suggests that anti-Asian sentiment drove restaurant avoidance beyond perceived risk of contracting COVID-19. Finally, we examined a potential driver of spillovers to non-Chinese Asian restaurants in ethnic misidentification. Consistent with our hypotheses, survey responses showed that individuals who incorrectly believed that the majority of Asian Americans were Chinese also expressed greater fear of Chinese food, and Trump support was a strong and significant positive predictor of avoidance of non-Chinese Asian restaurants and ethnic misidentification of Asian restaurants. Taken together, these findings indicate that anti-China sentiment-regardless of whether it was driven by fear or anger-triggered by COVID-19 and reinforced by US political rhetoric had a substantial role in consumer discrimination against Asian-owned restaurants.

Concerns about rising anti-Asian discrimination extend far beyond the consequences of the COVID-19 pandemic. Asian Americans have made up the plurality of immigrants to the United States since 2008 (ref. 100). Historically, the large increases in California's Chinese immigrant population during the nineteenth century were swiftly followed by a sharp increase in anti-Asian sentiment and discrimination, which persisted even after legislation stopped the flow of new immigrants from Asia12,101. In addition to this historical example, recent research102 has found that, as minority groups increase in rank in terms of their relative size (for example, to the largest minority group within a community), negative attitudes and violence towards these minority groups increase as well. Together with our own findings, these examples suggest that the United States may be entering a longer period of increased anti-Asian sentiment, which makes understanding the effects of discrimination against this group even more important.

Finally, although this research focuses on stigmatization and discrimination against Asian Americans, the findings have broader implications for public policy and communications strategy. Given the long history of stigmatization, discrimination and violence after major world events, this research underlines the responsibility of policymakers and officials to carefully consider the risks to minority and marginalized communities before responding.

Methods

Our research complies with all relevant ethical regulations. The Institutional Review Board for Health Sciences and Behavioral Sciences at the University of Michigan reviewed the survey studies and determined that they were exempt from further review. The anonymized and aggregated data do not involve 'human subjects' as defined. The participants were compensated for their time, and informed consent was obtained from all of the human participants in our surveys.

Data overview

We used four main data sources to determine the relationship between COVID-related anti-Asian sentiment and consumer discrimination against restaurants, including Google Trends, SafeGraph aggregate mobility data, surveys on anti-Asian attitudes and a survey on restaurant ethnic misidentification.

To broadly summarize, we used the web search data from Google Trends covering January 2016 to August 2020 to highlight the nature of the exogenous shock to American conceptions of China and Chinese food during COVID-19. We analysed movement data provided by SafeGraph over the period 4 November 2019 to 7 June 2020 to directly measure consumer discrimination in the form of visits to Asian (including both Chinese and non-Chinese) and non-Asian restaurants, supplementing our analysis with US elections and census data to examine heterogeneity in measured effects. We then turned to understanding the underlying psychological mechanisms behind these forms of discrimination. We gathered survey data from 4,000 Americans (in four waves fielded 5 May 2020, 27 August 2020, 29 October 2020 and 15 April 2021) to determine whether they blamed Chinese and other Asian American populations for COVID-19, and how this blame related to their beliefs about Chinese food safety. Finally, we used a survey of 2,345 Americans collected from 27 March 2021 to 8 May 2021 to understand whether the spillover effects were driven by ethnic misidentification of other Asian restaurants as Chinese restaurants. The full list of survey questions are provided in the Supplementary Information.

Search data

Weekly search data on US searchers from Google Trends enabled us to examine the role of the COVID-19 pandemic as an exogenous shock to anti-Asian sentiment during 2020. Google Trends data have been shown to be a powerful measure of racial animus103 that correlates strongly with a wide variety of outcomes, including electoral103 and health outcomes104. Supplementary Table 3 provides the full information on the search queries that we examined, which can be broadly classified into anti-China and food-safety related. We examined these queries at the weekly level from January 2016 to August 2020. Although there is occasional seasonality within search data (for example, people showing a special interest in Chinese food on Christmas Day), comparing searches over the course of five years eliminates the possibility that any patterns that we see in 2020 are the result of seasonal fluctuations.

Aggregate consumer mobility data

We analysed aggregate consumer mobility data provided by the firm SafeGraph using an observation period from 4 November 2019 to 7 June 2020. SafeGraph captures mobile device location data combined with labels defining the perimeters of approximately 5 million points of interest (POI) across the United States to generate weekly aggregated counts of visitors to each POI. We filter the week-POI aggregated visit counts to isolate data from 381,692 unique restaurant locations. We focused on restaurants specifically owing to their ubiquity, ease of affiliation between the business and a particular ethnic group, the increase in food-safety-related searches following COVID-19, and historical and contemporary use of food stereotypes as an outlet for xenophobic sentiment.

Attitudinal survey data

We ran two samples of 1,000 respondents for the same set of questions (noted as survey 1) conducted on 5 May 2020 (57% female; mean age, 43 years; age s.d., 16 years) and 27 August 2020 (55% female; mean age, 42 years; age s.d., 15 years) and a slightly updated version (survey 2) on 19 October 2020 (57% female; mean age, 38 years; age s.d., 13 years). We ran a final survey, also 1,000 respondents (49% female; mean age, 39 years; age s.d., 11 years), on 15 April 2021 (survey 3). The multi-waves were designed to capture the trends in our core questions of sentiment and behaviour as the pandemic progressed. Surveys were conducted within native advertising units in a mix of mobile applications on both iOS and Android, and in both mobile and desktop web experiences, using the Pollfish interface and delivery mechanism. The participants were at least 18 years old, and were randomly selected from the pool of eligible respondents. We asked a total of 25 questions in survey 1 and 18 questions in surveys 2 and 3 (see the Supplementary Information for a full list of questions, including both exploratory questions as well as specific questions to be used in this paper). These survey results were raked to reflect national Census estimates of key demographics.

Restaurant confusion survey data

We ran a separate survey study from 26 March 2021 to 8 May 2021 to examine the degree to which individuals distinguish between various Asian restaurants. A total of 2,345 American participants (51.3% female; mean age, 39.4 years; age s.d., 12.6 years) who were eligible to vote in 2016 and 2020 were recruited through Amazon Mechanical Turk (MTurk). The 2,000 restaurants in the pool were chosen in a stratified random sampling from among mono-ethnic restaurants in the SafeGraph dataset. Each participant was asked to classify a randomly selected set of 20 restaurants based on name alone from the pool of 2,000 real restaurants. Our stratification was chosen to balance between the most common ethnic restaurant cuisines while oversampling Chinese restaurants, as they were the focus of messaging and food safety concerns. The sample included 400 Chinese restaurants and 200 each of French, Indian, Italian, Japanese, Korean, Mexican, Thai and Vietnamese restaurants. The participants were also asked to self-report their gender, age, ethnicity and voting preferences in both the 2016 and 2020 American presidential election.

Panel regression model for measurement of pandemic traffic impacts

Our analysis of the consumer mobility data follows a difference-in-difference framework, measuring the differential impact of the onset of COVID-19 on visits to Asian versus non-Asian restaurants. This analysis controls for persistent differences in traffic for each restaurant and common temporal shocks. Specifically, we estimate the following equation:

$${\rm{logVisits}}{_{it}}={\beta }_{1}\times I({\rm{Asian}}_{i}\,\times \,{\rm{postCOVID}}{_{t}})+{\beta }_{2}\times {\rm{CaseRate}}{_{jt}}+{\eta }_{i}+{\delta }_{t}+{\epsilon }_{it}$$

In this model, i indexes restaurant locations and t indexes the weeks from 4 November 2019 to 7 June 2020. logVisitsi t is the natural log of the visit count to restaurant i in week t, and CaseRatej t is the number of per capita reported cases of COVID-19 in week t for the ZIP code j containing the restaurant i. Our difference-in-difference measure of interest is β ₁, which captures the interaction between whether the restaurant i is classified as an Asian restaurant and whether the time t is after 13 March 2020-the major onset of COVID-19 in the United States and declaration of National Emergency. η i denotes restaurant-level fixed effects capturing persistent differences in traffic for each restaurant location. These η i values collectively capture differences between Asian and non-Asian restaurants, and therefore replace the need for an indicator on Asian restaurants in the typical difference-in-difference specification. δ t captures common temporal shocks to traffic, such as if outdoor dining restrictions impacted all restaurants post-COVID or if there was a reduction in traffic due to national holiday.

This regression framework enables us to estimate the average traffic impact of the pandemic to Asian restaurants relative to non-Asian restaurants. Our specification is log-linear and, therefore, the estimated impact coefficient of −0.2013 can be interpreted as us observing an average decline in traffic of 18.4% (e −0.2013 = 1 − 0.184) for Asian restaurants in the post-COVID period when holding all other variables equal. This procedure is replicated to focus on the subsets of Chinese and non-Chinese Asian restaurants, holding the comparison group of non-Asian restaurants each time. Finally, the heterogeneity analysis calculates the impact coefficients separately for each ZIP code. These coefficients are visualized in Fig. 2 and regressed on the Trump 2016 vote share within the ZIP code while controlling for ZIP code median household income, college education and racial demographics to generate the results observed in Table 2.

We used a counterfactual simulation and back-of-envelope calculations to extrapolate the measured drop in Asian restaurant traffic into dollar terms. We simulated a counterfactual in which Asian restaurants suffered no relative traffic penalty versus non-Asian restaurants after the onset of COVID-19 by setting the interaction term in our regression model to zero. The model predicts that an additional 4.01 million SafeGraph-recorded visits to Asian restaurants would have occurred during our post-pandemic onset observation period, or an additional 13.2 million SafeGraph visits when prorated through the end of 2020. To perform the back-of-envelope calculation, we make the necessary and simplifying assumption that each restaurant's revenue is directly proportional to its SafeGraph traffic. The US Census Bureau estimates that total US restaurant revenue was US$584 billion in 2020 (ref. 105), which is allocated evenly across the estimated 1.04 billion SafeGraph restaurant visits in 2020. We therefore arrive at our estimate that American consumer avoidance of Asian restaurants led to $7.42 billion in lost revenue for those businesses in 2020.

Reporting summary

Further information on research design is available in the Nature Portfolio Reporting Summary linked to this article.

Acknowledgements

We thank the staff at SafeGraph for their free provision of aggregated consumer traffic data to support academic research and our survey participants for their time and attention; Monica Chan, Judith Han and Jared Katzman for their research assistance on this project; and the members of the Ross Behavioral Lab at the University of Michigan for support. We acknowledge the Stephen M. Ross School of Business, University of Michigan, for making funds available to J.T.H. and J.L.C.; Surveys on Pollfish were funded through a general survey research account at Microsoft Research. The authors received no specific funding for this work. Neither funders nor data providers had any role in study design, data collection and analysis, decision to publish or preparation of the manuscript. The findings and conclusions expressed in this article are those of the authors and do not necessarily reflect the views of their institutions. This paper is dedicated to the memories of two Asian Americans-Vincent Jen Chin and Balbir Singh Sodhi.

Author information

Authors and Affiliations

1. Marketing, University of Michigan, Ann Arbor, MI, US

Justin T. Huang

2. Political Science, Boston College, Boston, MA, US

Masha Krupenkin

3. Microsoft Research, New York City, NY, US

David Rothschild

4. Management and Organizations, University of Michigan, Ann Arbor, MI, US

Julia Lee Cunningham

Contributions

All of the authors developed the study concept, designed the study, wrote the paper and approved the final version of the paper for submission.

Corresponding authors

Correspondence to Justin T. Huang, Masha Krupenkin, David Rothschild or Julia Lee Cunningham.

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Competing interests

D.R. is an employee of Microsoft Research, but academic work is neither directed nor reviewed by Microsoft Research. The other authors declare no competing interests.

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Huang, J.T., Krupenkin, M., Rothschild, D. et al. The cost of anti-Asian racism during the COVID-19 pandemic. Nat Hum Behav 7, 682-695 (2023). https://doi.org/10.1038/s41562-022-01493-6
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DOI: https://doi.org/10.1038/s41562-022-01493-6

# data[].attributes.attachment_link.title
The cost of anti-Asian racism during the COVID-19 pandemic - Nature Human Behaviour

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Anti-Chinese sentiment increased during the COVID-19 pandemic, presenting as a considerable spike in overt violence and hatred directed at Asian American individuals. However, it is less clear how subtle patterns of consumer discrimination, which are difficult to directly observe yet greatly impact Asian American livelihoods, changed through the pandemic.

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27. The Impact of COVID-19 on Filipino Nurses: An Intersectional and scientific Look public Health 

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27. The Impact of COVID-19 on Filipino Nurses: An Intersectional and scientific Look public Health 

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Workforce Trends of Underrepresented Minority Nurses in the US in the last decade

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29. Racial/Ethnic Pay Disparities among Registered Nurses (RNs) in U.S. Hospitals: An Econometric Regression Decomposition

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29. Racial/Ethnic Pay Disparities among Registered Nurses (RNs) in U.S. Hospitals: An Econometric Regression Decomposition

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30. Increasing Racial/Ethnic Diversity in Nursing to Reduce Health Disparities and Achieve Health Equity

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30. Increasing Racial/Ethnic Diversity in Nursing to Reduce Health Disparities and Achieve Health Equity

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The compassion, resolve, and positive impact of nurses over the past few years cannot be overstated. From risking their lives as frontline health care professionals during the COVID-19 pandemic to working longer shifts in order to meet patient demand, nurses have more than earned their position as the most trusted profession for the 20th year in a row.

Nursing seems to be growing in every way. Diversity is increasing within the profession, and the demand for nurses is surging. Salaries are increasing in the field as well. These inflection points add to the widespread celebration of Nurses Month underway during May 2022. Sponsored by the American Nurses Association (ANA), Nurses Month is an annual event recognizing nurses for their tremendous effort and compassion, as they work collectively to improve the health of individuals, families, and communities nationwide. This year, their theme is as evergreen as it is prescient: Nurses Make A Difference.

Nurses at all levels and in all health care settings have played a critical role in the nation's continued fight against COVID-19. With approximately 4.2 million registered nurses and over 325,000 licensed nurse practitioners, the nursing profession continues to flourish.

Demographics

The current trends in nursing reveal an aging workforce that is slowly but steadily increasing in equality among two underrepresented groups in nursing: men and people of color. According to the 2020 National Nursing Workforce Survey, the average age of surveyed registered nurses was 52 years old, up from 51 in 2017. Nurses who are 65 years of age or older comprise the largest age category in the profession and represented 19% of the RN workforce in 2020, up from 14.6% in 2017 and 4.4% in 2013. The survey also found that men represent 9.4% of registered nurses, up from 9.1% in 2017, 8% in 2015, and 6.6% in 2013.

The report revealed the following racial demographics within the nursing field (2017 statistics in parentheses):

80.6% White/Caucasian (down from 80.8%)

7.2% Asian (down from 7.5%)

6.7% Black/African American (up from 6.2%)

2.3% Other (down from 2.9%)

2.1% More than one race category selected (up from 1.7%)

0.5% American Indian or Alaska Native (up from .4%)

0.4% Native Hawaiian or other Pacific Islander (down from .5%)

0.2% Middle Eastern/North African (2020 was the first survey with this category)

Additionally, 5.6% of RN respondents self-identified as Hispanic/Latino/Latina, up from 5.3% in 2017.

While men only represent 9.4% of registered nurses, the survey found that male nurses account for 13.6% of nurses of color, and 34.3% of nurses who identified themselves as Native Hawaiian or Pacific Islander.

When it comes to advanced practice registered nurses such as family nurse practitioners, studies show that diversity is increasing specifically when it comes to male nurse practitioners and Black nurse practitioners. In 2013, the BLS reported that only 8.2% of nurse practitioners were male and 5.8% were Black. By 2021, those percentages had grown to 12.6% male and 7% Black.

Demand

The demand for registered nurses (RNs) and family nurse practitioners (FNPs) remains high for several reasons. The aging population has a twofold effect on the nursing profession as both nurses and the patients they care for are growing older. Many nurses are nearing retirement age, and many patients are facing increased health care needs. Worldwide, 4.7 million nurses are expected to retire by 2030. When combined with the existing nursing shortage and aging Baby Boomer population, that results in the need for 10.6 million new nurses by 2030.

In the United States, the BLS projects that there will be about 194,500 openings for registered nurses every year through 2030 as nurses retire and patient demand increases. That represents a 9% growth rate in registered nursing jobs by 2030. This percentage translates to 276,800 new nursing jobs in the coming years.

As positive as the employment potential for registered nurses looks, the BLS predicts that demand for nurse practitioners (NPs) will be remarkably higher. They project an overall employment increase of 45% between the years 2020 and 2030, which is much faster than average for other occupations. The BLS attributes this growth to:

Increased focus on preventative care

Demand for health care services from the aging baby-boom population

Heightened use of team-based models of care

Changes in legislation that allow advanced practice registered nurses to perform more services

Growing cultural awareness of nurse practitioners as primary health care sources

The BLS expects to see approximately 29,400 openings for nurse anesthetists, nurse midwives, and nurse practitioners each year on average between 2020 and 2030. Factoring in retirement and other exits from the workforce, that represents 121,400 new jobs for advanced practice registered nurses-114,900 of which are projected to be for nurse practitioners-over the course of ten years.

Salary

Nursing statistics for salary are also a great sign of health and longevity for the profession.

Typical salaries vary depending on the geographic location and facility in which a nurse is employed, but the overall national picture is encouraging. The BLS reported a 2020 median annual income for RNs of $75,330.

The salaries are markedly higher for nurse practitioners, who earned a median wage of $111,680 as of May 2020.

Satisfaction

Registered nurses typically enjoy a high level of job satisfaction according to the latest nursing statistics.

In a 2021 survey of RNs, 81% of nurses said they were satisfied with their jobs. While the COVID-19 pandemic increased rates of nurses feeling burned out or emotionally drained, 66% said they planned to remain at their current jobs, which is actually an increase from the 2019 statistic of 64%.

Nurse practitioners also enjoy high levels of job satisfaction. U.S. News & World Report ranks the profession as #1 in Best Health Care Jobs and #2 in the 100 Best Jobs overall. Nurse practitioners do tend to experience above average levels of stress, but they enjoy above average opportunities for upward mobility through career advancements and salary increases.

Trusted

The public deeply and overwhelmingly trusts nurses. As noted in the introduction, the Gallup's annual Most Honest and Ethical Professions Poll ranked nurses in the number one position for the 20th year in a row. Not only that, but 81% of Americans polled stated that nurses' honesty and ethical standards are "very high" or "high." The second-highest profession only reached 67%, highlighting the unique, positive impact of nurses on the lives of individuals.

Nurses are trusted greatly because they serve as both confidantes and liaisons between doctors and family members. This level of professional respect, combined with the fact that nurses have dedicated their lives to helping others, make the profession difficult to surpass in integrity, especially during a pandemic and pandemic recovery.

Nursing Statistics Summarized

The average age of surveyed registered nurses is 52 years (NCSBN).

9.4% of nurses are male, versus 6.62% in 2013 (NCSBN).

Nurses who are Black, multiracial, or Native Hawaiian/Pacific Islander are increasing in representation (NCSBN).

Registered nurse jobs are growing at an average pace of 9% by 2030 (BLS).

Nurse practitioner jobs are growing much faster than average at 45% by 2029 (BLS).

Registered nurses can anticipate 276,800 potential new job openings by 2030 (BLS).

Nurse practitioners can anticipate 114,900 potential new job openings by 2030.RNs earned a median annual salary of $75,330 as of May 2020 (BLS).

The median salary of nurse practitioners is over $111,000 per year (BLS).

81% of nurses are satisfied with their current jobs (AMN Healthcare).

Serving Communities and Beyond

Nurses serve as both the frontline and backbone of quality patient care. With the arrival of National Nurses Month, the staff and faculty at Carson-Newman University thank everyone who has dedicated their career to nursing and continues to touch lives with compassion.

Carson-Newman offers expert clinical preparation and a Christian-centered curriculum for those who aspire to become family nurse practitioners (FNPs). Through our affordable and convenient online FNP program, which provides clinical placements, you can broaden your impact and make holistic patient care more accessible in your community.
About Carson-Newman's Online FNP Programs
Founded in 1851, Carson-Newman is a nationally ranked Christian liberal arts university. An online, yet personal, learning environment connects you with fellow students, faculty, and staff. Faith and learning are combined to create evidence-based online graduate nursing programs designed to transform you into a more autonomous caregiver.

Through its online program and student-centric curriculum, Carson-Newman provides a life-changing education where students come first. Designed for working nurses, Carson-Newman's affordable FNP programs feature 100% online coursework with no mandatory log-in times, clinical placement service, and exceptional individualized support that prepare graduates to pass the FNP licensure exam.

If you're ready for the next step in your nursing career, consider the online Master of Science in Nursing - Family Nurse Practitioner offered by Carson-Newman University and accredited by the CCNE.

For those who already hold an MSN degree, consider pursuing a Post-Master's FNP Certificate to enjoy all the leadership opportunities, job satisfaction and autonomy of a family primary care provider. For more information, visit onlinenursing.cn.edu.

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Nursing Statistics 2022 - By the Numbers | Carson-Newman

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The compassion, resolve, and positive impact of nurses over the past few years cannot be overstated. From risking their lives as frontline health care professionals during the COVID-19 pandemic to working longer shifts in order to meet patient demand, nurses have more than earned their position as the most trusted profession for the 20th year in a row.

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From: http://notesfromtheapotheke.com/unlocking-the-cycle-of-departmental-allyship/

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36. Free Article: DRAG THEM: A brief etymology of so-called "cancel culture"

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The term "cancel culture" has significant implications for defining discourses of digital and social media activism. In this essay, I briefly interrogate the evolution of digital accountability praxis as performed by Black Twitter, a meta-network of culturally linked communities online. I trace the practice of the social media callout from its roots in Black vernacular tradition to its misappropriation in the digital age by social elites, arguing that the application of useful anger by minoritized people and groups has been effectively harnessed in social media spaces as a strategy for networked framing of extant social problems. This strategy is challenged, however, by the dominant culture's ability to narrativize the process of being "canceled" as a moral panic with the potential to upset the concept of a limited public sphere.

In July 2020, Harper's Magazine published "A Letter on Justice and Open Debate" signed more than 150 notable public figures who aligned to speak out against the development of "a new set of moral attitudes and political commitments that tend to weaken our norms of open debate and toleration of differences in favor of ideological conformity," or more colloquially put, the threat of "cancel culture." While limited in scope, I use this essay to briefly map an etymological examination of "canceling" as digital discursive accountability praxis, from its origins in Black oral tradition to its misappropriation by social elites. I begin with a definition of what it means to be "canceled" by contextualizing the power relations that inform the assumption of an equitable public sphere. I then call on digital intersectionality theory to explicate the roots of Black digital discursive practice. Finally, I argue that while social media callouts are a form of networked framing ( Meraz & Papacharissi, 2013), they have been effectively and tellingly counter-framed through application of the reductive and malignant label "cancel culture."

Called out, called in, canceled

Jonah Engel Bromwich, a style writer for the New York Times described the digital phenomenon of being canceled as "total disinvestment in something (anything)" (2018, npa). As I explained to him, "canceling" is an expression of agency, a choice to withdraw one's attention from someone or something whose values, (in)action, or speech are so offensive, one no longer wishes to grace them with their presence, time, and money. The term has since devolved into journalistic shorthand wielded as a tool for silencing marginalized people who have adapted earlier resistance strategies for effectiveness in the digital space.

"Cancel culture" is situated within the Habermasean concept of the public sphere which assumes public discourse is the realm of the elites ( 1962). Earlier examples of discursive accountability practices, including reading, dragging, calling out, in and even canceling, are the creations of Black counterpublics that are conspicuously absent from the American public imaginary, which holds a lofty vision of newspaper op-ed pages, radio shows, town-hall meetings, and the like as forums of debate where a multiplicity of discursive publics are equally empowered to engage in debate and the free expression of ideas. This simply isn't so.

For instance, canceling's analog antecedents-blacklisting and boycotting-are also mediated processes, though limited both in scope and effectiveness by factors of structural power, time, and access to resources. Producers and casting directors, for example, have the ability to categorically deny employment in the entertainment industry. Admissions officers, regents, and donors have enjoyed similar influence on college campuses. Even the measured success of Civil Rights era boycotts depended on global media attention to gain traction. Thus, any examination of so-called "cancel culture" must begin with an analysis of the power relations by which it is defined. Only a perspective that prioritizes the communication histories and practices of disempowered people can adequately decipher the phrase's use as a tool to delegitimize the dissension that echoes from society's margins.

Canceling a person, place, or thing is socially mediated phenomena with origins in queer communities of color. Black Twitter-the meta-network of culturally connected communities on the microblogging site ( Clark, 2015)-made the language of being "canceled" into an internet meme ( Shifman, 2013). The reference was subsequently seized upon by outside observers, particularly journalists with an outsized ability to amplify the(ir own) white gaze. Politicians, pundits, celebrities, academics, and everyday people alike have narrativized being canceled into a moral panic akin to actual harm, adding a neologic twist on the origin of the practice by associating it with an unfounded fear of censorship and silencing. But being canceled-a designation, it should be noted, usually reserved for celebrities, brands, and otherwise out-of-reach figures-should be read as a last-ditch appeal for justice.

"Originally a practice of Black women 'signifyin,' [the callout] has occasionally been mistaken for Twitter's 'mob mentality,' but it is qualitatively different: it is often a critique of systemic inequality rather than an attack against specific, individualistic transgressions" (Brock, 2020). As venture community management, the callout on social media platforms such as Twitter is a form of activism; feminized labor in the digital economy undertaken voluntarily to protect the particularly vulnerable in online spaces ( Nakamura, 2015). The use of broadcast-style social media platforms, such as Twitter and YouTube, allow marginalized groups to engage in networked framing, a process by which collective experiences of an offending party's (or their proxy's) unjust behavior is discussed, morally evaluated, and prescribed a remedy-such as being fired or choosing to resign-through the collective reasoning of culturally aligned online crowds ( Meraz & Papacharissi, 2013, p. 159).

It may involve reading another individual-giving them a dressing down that uses colorful and descriptive language and an incisive ability to articulate appraisal of another's character. Reading, which begat calling out (which begat canceling), is an "indigenous expressive form" particular to the Other. It has been perfected by Black women like our grandmothers, who let us know what they see, even if they don't directly say it; minors deprived of a sense of agency, who quickly learn how to detect and name adults' ulterior motives; and queer folk whose first line of defense is withering critique ( Johnson, 2011, pp. 434, 437, and 443). While these interactions usually go unnoticed, the clashes between strong and weak publics, particularly on Twitter, expose the conceptual limits of a singular public sphere for the chaotic deliberation required in the development of a truly liberal democracy ( Fraser, 1990, p. 77). Not every critique can come wrapped up in niceties and polite speech. Nor should it. Sometimes, the urgency and weight of oppression require us to immediately cry out.

The idea of "cancel culture," as implied by the letter, is a phenomena uniquely enabled by capitalism's demands on the media production side, and on the audience side, by our connectivity to social media. Social media is a space where journalists-who possess the ability to amplify otherwise unremarkable conversations-have extracted and decontextualized so many rich traditions of Black communicative practice to meet the demand for media content that will draw readers/listeners/viewers' attention, while failing to provide adequate cultural context to explain why these debates are and should be a part of mainstream public discourse. As Tynes et al. (2012) explain in their advancement of digital intersectionality theory: "Countering dominant discourses on social media as conversation is intersectional, multidimensional and less restricted. This enables users to effectively 'talk back' and mobilize around topics outside the view of the mainstream, until they go viral, at which point they gain the desired attention of the [mainstream news] media" (p. 33; emphasis and qualifiers mine).

You gon' learn . . . but we got to teach ya

In 2013, during Black Twitter's summer of accountability, celebrity chef Paula Deen, Juror B37 in the trial of Trayvon Martin's killer, and white feminists everywhere were examples of this back talk when their acts of workplace bigotry, opportunism, and limited commitments to solidarity (respectively) were called out via hashtags and an online petition. Aside from Deen's hostile workplace lawsuit, none of these incidents would have been considered substantive enough to warrant news coverage, but Black Twitter's online activity around each of them triggered news media systems, demanding coverage. Hashtag-driven discussion of these incidents, as well as cases in which ordinary people are caught on tape attempting to police and harass Black folks (#BBQBecky, #PoolPatrolPaula), push the ever-present issue of everyday racism to the top of the news media's agenda. Several of the Harper's letter signatories have been at the center of these processes, where the online discourse of the undifferentiated masses characterizes debate about fitting punishment for people who break with evolving social norms. The rapid mobilization in digital resistance and accountability practice among otherwise disempowered peoples compel us to identify who or what defines the disputed concept of the public sphere, who sets the rules of engagement, and thus what is considered "talking back" to dominant discourses.

James Davison Hunter, a sociologist and author of the 1990s culture wars thesis mapped these contours of power perfectly, declaring that "public discourse is a discourse of elites. That is where you find this conflict at its most incendiary. . . . The power of culture is the power to define reality, the power to frame the debate, and that power resides among the elites." Thus framing these unruly discourses as "cancel culture" has found utility among those who wish to quash any attempts to critique their social position. It evokes the enduring schema of an ongoing battle between those Hunter conceived of as elites-those with advantageous positions in the Matrix of Domination ( Collins, 1990)-and everyone else. Hunter belies the shared belief among those who promote the culture wars thesis as their investment in the limitations of the Habermasean public sphere concept, which privileges the elite class and allows no room for alternative and dissenting public, nor acknowledges relations between powerful and disempowered groups ( Fraser, 1990, p. 77). While Fraser's critique of "actually existing democracy" provides four clear objectives for critically theorizing the public sphere concept that the signatories of the Harper's letter claimed to defend, too much attention is paid to its limitations. I prefer the expansiveness offered by Lorde's theory of "useful anger" as guide to reconciling the uppity, loud, slick, cutting, and unrelenting critique levied as unruly speech ( Olson, 2011):

We are working in a context of oppression and threat, the cause of which is certainly not the angers which lie between us, but rather that virulent hatred leveled against all women, people of Color, lesbians and gay men, poor people against all of us who are seeking to examine the particulars of our lives as we resist our oppressions, moving toward coalition and effective action. ( Lorde, 1984)

Social media allows hundreds of thousands-if not millions-of everyday people to leverage networked collectivity and a sense of immediacy to demand accountability from a range of powerful figures, including individuals-such as Russell Simmons' ill-conceived #HarrietTubmanSexTape; and institutions-such as the universities called out by #ConcernedStudent1950 and #BeingBlackAtMichigan. For so long, the concentric circles of the social elite in arts, media, business, and politics were insulated by the norms of acceptable discourse, distanced from the realities of Others who struggle through life without access to the specific privileges afforded along lines of race, gender, and class. As digital connectivity shrinks those gaps, the demand for new social standards outpaces the willingness of the comfortable to consider just what their professed commitment to the promotion of social equity may actually cost them. Unfortunately, the expansiveness of the internet and its outsize influence on news and entertainment media doesn't bode well for parsing the nuance of such clamorous conversation. The noise of online harassment, doxxing, and bad-faith piling on that has evolved from the callout, the read, and the drag drowns out Black Twitter's approach toward demanding accountability in digital spaces.

The problem with so-called "cancel culture" does not rest with the formerly disempowered, seemingly faceless public that the letter critiques, but with the signatories and their peers, " . . . the institutional leaders," who, "in a spirit of panicked damage control, are delivering hasty and disproportionate punishments instead of considered reforms." These self-appointed regents of open debate have failed to anticipate an age in which there is no longer a dominant public sphere, but a fractal sequence of counterspheres and oppositional publics. They have yet to reconcile how coalitions of the Othered are now equipped to execute a responsive strategy for immediately identifying harms and demanding consequences. The absence of deliberation in chastising bad actors, misconstrued as the outcome of cancel culture, is a fault of the elites' inability to adequately conceive of the impact social media connectivity has for shifting the power dynamics of the public sphere in the digital age.

In their attempt to separate Black discursive accountability praxes-calling out, reading, and canceling-from their origins in the creative spaces occupied by the oppressed, and reposition them as a threat to their real and aspirational peers, elite public figures fall victim to their own worst fears: a realization that the social capital they've worked so hard for is hyperinflated currency in the attention economy.

References

Clark, M. D. (2015). Black twitter: Building connection through cultural conversation. In Rambukkana, N. (Ed.), Hashtag publics: The power and politics of discursive networks (pp. 205-217). Peter Lang Press.
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Collins, P. H. (2000). Black feminist thought: Knowledge, consciousness, and the politics of empowerment. Routledge.
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Habermas, J. (1962). The structural transformation of the public sphere: An inquiry into a category of bourgeois society. Herman Lutcherhand Verlag, Darmstad and Neuwid, Federal Republic of Germany.
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Lorde, A. (1984). Uses of anger: Women responding to racism. In Lorde, A. (Ed.), Sister outsider: Essays & speeches (pp. 124-133). Crossing.
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Olson, L. (2011). Anger among allies: Audre Lorde's 1981 keynote admonishing the National Women's Studies Association. Quarterly Journal of Speech, 97(3), 283-308.
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Tynes, B., Schuschke, J., Noble, S. U. (2016). Digital intersectionality theory and the #BlackLivesMatter movement. In Noble, S. U., Tynes, B. (Eds.), The intersectional internet: Race, sex, class, and culture online (pp. 21-40). Peter Lang.
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Author biography

Meredith D. Clark is an assistant professor in the Department of Media Studies at the University of Virginia. She is the author of a forthcoming manuscript on Black Twitter. She can be reached on Twitter @meredithdclark.

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DRAG THEM: A brief etymology of so-called "cancel culture" - Meredith D. Clark, 2020

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The term "cancel culture" has significant implications for defining discourses of digital and social media activism. In this essay, I briefly interrogate the evolution of digital accountability praxis as performed by Black Twitter, a meta-network of culturally linked communities online.

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Nursing Justice: Filipino Immigrant Nurse Activism

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Nursing Justice: Filipino Immigrant Nurse Activism

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Nursing Justice: Filipino Immigrant Nurse Activism in the United States

By Catherine Ceniza Choy *

When you think about trailblazing women in American nursing history, do Filipino nurses come to mind? Probably not. But they should.

The pioneering cancer prevention work of Ines Cayaban in the 1940s, the organizing work of Esther Hipol Simpson to defend two immigrant nurses wrongfully accused of murder in the 1970s, and the current leadership of National Nurses United Co-President Zenei Cortez to demand adequate personal protective equipment (PPE) are just three examples of notable Filipino immigrant nurse activism in the United States.

Attention to the impact of their lives and work is timely. The WHO designation of 2020 as the International Year of the Nurse and the Midwife was meant to be celebratory. Tragically, it has become a year of tremendous loss, grief, and anger. Many Filipino nurses have died on the COVID-19 front lines. As community educator Isa Cajulis has argued, Filipino nurses are not disposable. And as storyteller Christine Bumatay has emphasized, Filipino migrants deserve our attention.

Ines Cayaban: Public Health Nurse and Cancer Prevention Pioneer

Ines Cayaban was born in 1904 in the Philippine province of Ilocos Norte. American colonization of the Philippines had begun less than a decade prior, quickly shaping her formative years of schooling and her life ambitions.

Ines's migration was part of a pioneering wave of early-twentieth-century Filipino student migrations that included nurses, a precursor to Filipino nurse mass migration to the United States in the second half of the twentieth century. As Ines completed her nursing studies in the Philippines in the 1920s, she set her sights on going to the United States.

By that time, a small group of Filipino nurses had returned after furthering their nursing studies in the United States and replaced white American nursing supervisors in Philippine hospitals. Thus, Ines and other nursing students quickly learned that education in the United States was the pathway for professional advancement in the Philippines. Three years after graduating from St. Luke's School of Nursing as class valedictorian in 1928, she left the Philippines to further her studies at Columbia University.

The U.S. colonial government expected Filipino nurses on scholarship abroad to return to the Philippines. However, a stopover in Hawaii disrupted Ines's intentions and American colonial plans. She married a Filipino American whom she met in Hawaii and settled there, becoming what historians Barbara Posadas and Roland Guyotte have called an "unintentional immigrant."

Ines initially worked as a public health nurse at Palama Settlement for low-income and immigrant communities. In 1949, she joined the Hawaii Cancer Control Society's Education Department. In her autobiography, A Goodly Heritage, Ines wrote:

What I wish to point out is that during the early days of our cancer control programs, non-Caucasian women were ashamed to have a pelvic examination, especially in having a smear taken from the cervix for the Pap test. The Filipino women were very shy at being examined 'down below', particularly by a male physician. It took quite a long time to convince them that periodic pelvic examination was very essential in discovering cancer in its early stages, and insuring a high rate of cure.

Ines Cayaban's sensitivity to gender and racial differences, her ability to speak multiple languages and her willingness to learn new ones, and her skill in using different forms of media from print to radio to television contributed to the effectiveness of her work in cancer prevention. She lived the remainder of her life in Hawaii, and passed away in 1997 at age 92.

Esther Hipol Simpson: Anti-Martial Law and Anti-Racist Activist

By 1973, when Esther Hipol Simpson left the Philippines to work as a nurse in Chicago, so much had changed from the early 20th century. The Immigration Act of 1965 had overhauled U.S. immigration policy. It ended overtly discriminatory immigration policy toward Asia and other parts of the world and established a preference system that favored the immigration of highly-educated persons with needed skills. And what the United States needed then was nurses, especially in hard-to-recruit areas such as inner-city and rural hospitals.

Recruiters targeted nurses in the Philippines because of their Americanized training. Beginning in the late 1960s, tens of thousands of Filipino nurses utilized the preferences of the 1965 Act to immigrate to the United States.

While dreams of travel and adventure enticed Filipino nurses, others left the Philippines because they were frustrated with the lack of job opportunities in their home country. I had the privilege of interviewing Esther in Seattle, Washington, in 1994. When I asked her why she decided to immigrate to the United States, she expressed ambivalence: "I wouldn't have left the Philippines in the first place if the opportunities had been much better."

While Esther pursued job opportunities in Chicago, she also began to develop a new transnational political consciousness. She became involved in the nascent Anti-Martial Law Movement in the United States that opposed Philippine President Ferdinand Marcos's imposition of martial law in 1972. She joined the Chicago chapter of the KDP (Union of Democratic Filipinos), an organization that focused on social and political issues in both the United States and the Philippines. The KDP took seriously racial discrimination faced by Filipinos in the United States, especially because of the rapidly increasing number of Filipino nurses.

As an activist, Esther was involved in multiple campaigns to support Filipino nurses. One included the defense of two Filipino immigrant nurses, Filipina Narciso and Leonara Perez, who were wrongfully accused of poisoning and murdering patients at the V.A. Hospital in Ann Arbor, Michigan. After determining that these nurses had been scapegoated because of their race, gender, and immigrant status, Esther worked with the KDP and the Chicago Support Group for the Defense of the Narciso-Perez Case to provide them with a proper defense and to demand a new trial after the two nurses were convicted of conspiracy and poisoning in July 1977.

Esther and fellow activists held forums, organized fundraisers, and coordinated demonstrations and petitions. In large part due to their efforts, the U.S. Attorney dismissed the case against Narciso and Perez in February 1978 and the immigrant nurses were set free.

Esther passed away in 2018 in Seattle, Washington. In the anthology A Time To Rise: Collective Memoirs of the Union of Democratic Filipinos, she reflected upon her activism: "This effort was a great and noble experience working for democratic rights and justice. I would do it all over again."

Zenei Cortez: Co-President of National Nurses United

Filipino laborers in the United States, most notably farm workers, have a century-long experience of organizing. Filipino immigrant nurses are also part of this formidable history. One prominent example is Zenei Cortez, the first Filipino to be elected president of the California Nurses Association/National Nurses Organizing Committee. Zenei is currently a co-president of National Nurses United, the largest union and professional association of registered nurses in U.S. history.

Born and raised in the Philippines, Zenei migrated to the United States with her parents and siblings in 1974. As a registered nurse, she has worked through multiple pandemics and disease outbreaks, including AIDS, SARS, H1N1, Ebola, and now COVID-19.

Zenei's decades-long work history in bedside, direct-care nursing has given her a critical historical lens to view the shortcomings of the United States's handling of the current pandemic. In a March 2020 interview with Sarah Jaffe for The Nation, she decried the shortage of PPE for nurses:

"We are in America, one of the richest countries in the world and, yet, nurses who have given themselves to the frontlines are being denied something very important to protect ourselves and our patients. I have been a nurse for 40 years, and this is the first time this is happening."

Zenei utilizes her leadership platform to also speak out against a broken American health care system where nurses and other health workers are being told to do more with less.

"COVID has exposed everything that has been wrong with our system," Zenei said, during a National Day of Action in August 2020 that involved thousands of American nurses. "The old way was a huge failure. Now is the time to reenvision a world based on nurses' values of caring, compassion, and community."

We tend to think of Filipino nurse migration to the U.S. as something new. However, the lives and work of these three Filipino immigrant nurses span the early twentieth century into the twenty-first. Despite their longstanding presence and large numbers in the United States, Filipino nurses like Ines Cayaban, Esther Hipol Simpson, and Zenei Cortez are hidden figures in American nursing history. This too must change.

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Nursing Justice: Filipino Immigrant Nurse Activism in the United States

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By Catherine Ceniza Choy * When you think about trailblazing women in American nursing history, do Filipino nurses come to mind? Probably not. But they should.

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Bill Nye Uses Science to Explain Why Racism Doesn’t Make Sense | NowThis

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Bill Nye Uses Science to Explain Why Racism Doesn’t Make Sense | NowThis

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Bill Nye Uses Science to Explain Why Racism Doesn’t Make Sense | NowThis

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African Americans, Slavery, and Nursing in the US South

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African Americans, Slavery, and Nursing in the US South

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African Americans, Slavery, and Nursing in the US South

By R.J. Knight *

In 2016, a statue of Jamaican-born nurse and businesswoman Mary Seacole was erected outside St Thomas' Hospital in London. Seacole's contribution to the war effort in the Crimea and to British life is well-known. Yet, the tribute - the first statue of a named Black woman in the UK - gathered vocal opposition from The Nightingale Society, which assembled to oppose the decision and "defend" Florence Nightingale's reputation as Britain's premier nurse. In essence, its members do not view Seacole as a "proper" nurse.

The opposition speaks to a persistently narrow view of the history of nursing. Nursing has been expansive, encompassing many forms of work, knowledge, and experience. It has been practiced in many settings. It has also been racialized, as well as gendered, work. In numerous historical contexts, women of color have experienced barriers to opportunities, inclusion, and advancement in nursing, and at the same time, have performed the bulk of nursing work and played key roles in developing nursing knowledge and practices. These complexities in the history of nursing are made especially clear by centering enslaved African American women. Indeed, while Seacole and Nightingale were in Crimea, around four million African Americans were enslaved in the American South. They labored in every capacity imaginable, including as nurses.

In the nineteenth century, while enslaved people were increasingly treated in medical institutions in towns and cities, many slaveholders established hospitals or "sick houses" on their own plantations. A "good" sick house was one that allowed for "attendants to lock the patients in," and in these settings enslaved people confronted at once their enslavers' economic interests, coercive power, and racist beliefs around their capacity for pain. Most notoriously, in a purpose-built hospital on a farm in Montgomery, Alabama, physician and surgeon James Marion Sims experimented with the repair of vesicovaginal fistula on about twelve enslaved women, including Anarcha, Betsey, and Lucy. He operated without anesthetic. Historian Deirdre Cooper Owens has shown how these women continued to "perform the duties slaves were expected to complete" during the five-year "experiment." Enslaved women cared for Sims's sick child and, as skilled medical workers, served as Sims's surgical nurses. Hospitals were at once sites of enslaved people's struggle for autonomy over their bodies and their forced labor.

Physicians generally visited sick houses as slaveholders requested, and hospitals were supervised by overseers and slaveholders. White female slaveholders also took roles in enslaved people's healthcare. Victoria Adams described to a Federal Writers Project interviewer in the 1930s how her "mistress" used to "look after de slaves good when they was sick" in Cedar Creek, South Carolina, using medicines made from herbs, leaves, and roots. Caregiving was a vehicle for their economic interests. As formerly enslaved woman Sarah Douglas described: "If I got sick old miss would give me plenty of medicine because she wanted me to stay well in order to work." Nursing was not interchangeable with nurturing, and female slaveholders regularly complained of the burdens of caring for those they characterized as incompetent and irresponsible shirkers and malingerers.

It was enslaved women who supplied the bulk of the daily nursing work on plantations. Some received their training from white doctors. When Clara Walker was thirteen years old, her "mistress" sent her to a doctor "who learned me how to be a midwife" over five years during her enslavement in Arkansas. Clara "made a lot o' money for old miss," delivering white and Black children. Few received such apprenticeships. Treatments, practices, and beliefs were passed down from older community members, and enslaved women merged African, Caribbean, Indigenous, and European medical knowledge in their work. Women were particularly renowned for their expertise in the reproductive realm, and "grannies" and midwives helped to manage pregnancy, childbirth, and childrearing within the "female slave network." As skilled medical practitioners, and nurturing caregivers, enslaved women were highly valued in their families and communities. Bacchus White conveyed enslaved people's conviction in their female healers: "anything Aunt Judy couldn't do 'hit won't wurth doin'." Enslaved women sustained life, eased pains, and healed.

Whites, on the other hand, found themselves reliant on the medical skills of enslaved people but skeptical of - or reluctant to recognize - their abilities. They often characterized enslaved women as superstitious, uninformed, and injurious. Enslaved people's expertise troubled racist constructions of African Americans' intellectual capacities, and slaveholders' denigration and recognition went hand-in-hand. In Georgia in the 1830s, for instance, plantation mistress Fanny Kemble debased enslaved people's medicine as the "simple remedies" of "ignorant" "savages," yet noted these were "generally approved by experience, and sometimes condescendingly adopted by science" and physicians. The work of nurses was also the "fatiguing, repetitive, and dirty" work of caring for the sick, and thus, as historian Sharla Fett writes, enslaved people's roles in healthcare exhibited "contradictions between skill and servitude."

In slaveholding households, nursing was equally expansive and beset with contradictions. Enslaved women performed elder-care, nursed white women through childbirth, and cared for those suffering all manners of disease and injury. Enslaved women fed and washed patients, administered medicines, dressed wounds, and changed beds. In the domestic realm "nurse" was a noun, as well as a verb, and commonly referred to an enslaved person who cared for white children. These nurses were chosen from slaveholders' existing laborers, or women could be bought or hired explicitly for this work. They watched, fed, bathed, dressed, held and played with children, and cared for them in illness. Enslaved women's experience and talents were valued by their enslavers. White women remarked on their children's affection for their Black caregivers, and their abilities to soothe fretful babies.

Slaveholders simultaneously complained about nurses' shortcomings and were quick to punish perceived transgressions. Value did not necessarily equate to privilege: nurses worked in close confines with abusive slaveholders, frequently changed hands, and experienced separation from their families. They were called upon to do all manner of household tasks, worked day and night, and were often forced to travel with whites. While this posed particular challenges for adult women with families, many enslaved nurses were just children. Sylvia Cannon was "just a little small girl" when Earlie Hatchel bought her for a nurse. Hatchel put the baby in Cannon's lap and instructed her "don' drop him." While the infant slept, Cannon did other work in the house. In turn, enslaved children themselves became experienced nurses. That nursing children could be both specialized labor and part of wider working responsibilities, required much and little experience, complicates the definitions of skilled and unskilled work.

Another common use of the term "nurse" was in reference to breastfeeding. It was not unusual for enslaved women to wet-nurse their enslavers' infants. This form of nursing demanded intimate bodily and emotional labor. Many enslaved wet-nurses were actually bereaved of their own babies when forced to take on this work. Other Black women coerced into breastfeeding white infants had to balance their enslavers' demands against feeding their own children, or relinquish them to other caregivers. Indeed, to allow enslaved women in their "prime" years to labor unhindered by their infants, many slaveholders instituted collective forms of childcare, whereby a plantation "nurse" would take charge of all the enslaved children. In Georgia, Lina Hunter described how her great-granny Rose looked after the enslaved children while their parents worked, with the assistance of the older children. Rose "had 'em all day, and she had to "see dat dey had de right sort of victuals to make chillun grow fast and strong."

Slavery was an intricate web of care and capital, and from the hospital to the household, it depended on enslaved women's nursing to sustain Black and white lives. And yet, in their medical knowledge, as medical practitioners and caregivers, women also threatened the system of slavery. Enslaved women appreciated that certain substances had abortive and contraceptive properties, and "king cotton" itself could be consumed to control reproduction and deprive slaveholders of chattel. Colonial laws acknowledged that medicine could be used to malicious ends: a 1748 Virginia law recognized "poisonous medicines" might be administered under the "pretence of practicing physic." These legal provisions implicitly acknowledged the power of enslaved people, but also rendered them vulnerable to accusations that had serious and even deadly consequences. In 1860, for instance, one enslaved woman called Fanny was accused of poisoning the white child she was hired to nurse by the Luck family in Richmond, Virginia. Fanny, they alleged, had attempted to fashion a pill from blister salve and force it "down the babe's throat" after an altercation with Mrs Luck. The Daily Dispatch thought Fanny would surely be executed, but - valued at a sum of $1000 - she was instead sentenced to transportation outside of the U.S. Fanny maintained her innocence.

The varied dimensions of nursing under slavery highlight that this work has encompassed exploitation and power as much as intimacy and care, forced labor as well as free, and has served both communities and regimes. This work has been both valued and unrecognized, construed as skilled and unskilled. A narrow view of nursing's history does not allow for this expansive and complicated past, nor the unique contributions and experiences of Black women nurses.

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African Americans, Slavery, and Nursing in the US South

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In 2016, a statue of Jamaican-born nurse and businesswoman Mary Seacole was erected outside St Thomas' Hospital in London. Seacole's contribution to the war effort in the Crimea and to British life...

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Nursing for Generations: Kiowa Peoplehood in the Work of Laura Pedrick

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Nursing for Generations: Kiowa Peoplehood in the Work of Laura Pedrick

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Nursing for Generations: Kiowa Peoplehood in the Work of Laura Pedrick

By Jessica J. Hauger *

When smallpox erupted across the Kiowa, Comanche, and Apache Reservation in 1900, local people began to panic. Experienced Kiowa and Comanche healers knew smallpox as a Western disease that usually required Western treatment. Rocky plains made difficult passage for the horse-drawn buggies that Charles Hume and Harry Wheeler, the reservation's two government physicians, used to make their calls. But across three million acres of those plains, four thousand potential patients lived, worked, and slept. Something had to be done.

Arriving during Carlisle's first year of operations, T'oyhawlma became part of the first generation of Native students to experience the force of assimilation policy from within its doors. There, she grew familiar with Christianity and corsets, white bread and her new name. Laura also met Native youth from across North America and learned about what happened in their homes, about their own losses at the hands of soldiers and settlers, knowledge which apparently motivated Pedrick and many other Native youth to seek socio-economic uplift for Indigenous people across North America.

This program, then, rested on an ethic of settler colonization that sought to eliminate tribal sovereignty through the abolition of Indigenous cultural practices, kinship networks, and political structures. As a field matron, Pedrick undoubtedly perpetuated rhetoric that decried traditional housing, foodways, and religion as detrimental to Indigenous people's well-being. Her field matron reports contain the language of assimilation policy, noting disapproval of some Kiowa traditions and expressing hope for the conversion of her people to Christianity and "civilization." This rhetoric contributed to constrictions of tribal sovereignty, hurt Indigenous people's ability to build self-determined lives, and led to losses of cultural knowledge.

As a nurse, Pedrick had responded to an unfulfilled need for reliable care in times of illness. But her work was not simply a crisis response. At a time when infectious diseases devastated reservation communities across North America, good health resisted the federal government's eliminatory strategies. Pedrick knew that substandard rations, housing, and medical infrastructure left her people more vulnerable not only to disease, but to the social, economic, and political predation of settlers and the federal government.

Particularly in the months before the reservation was opened to white settlement in 1901, Pedrick feared for her people. She wrote that she spent

a considerable portion of my time nursing and caring for sick, and learning others to do the same. I try to make them see, that a great change is about to come upon them. That in the future they will have to receive white people upon their reservation...we who are employed to help them should I think prepare ourselves for the struggle of our life in their behalf.

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Nursing for Generations: Kiowa Peoplehood in the Work of Laura Pedrick

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By Jessica J. Hauger * When smallpox erupted across the Kiowa, Comanche, and Apache Reservation in 1900, local people began to panic. Experienced Kiowa and Comanche healers knew smallpox as a Western disease that usually required Western treatment.

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16 AAPI Nurses To Know for Asian Pacific American Heritage Month

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16 AAPI Nurses To Know for Asian Pacific American Heritage Month

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Perseverance and pride mark Asian Pacific American Heritage Month in May as we celebrate the men and women who have stood on the front lines during COVID-19. Unfortunately, the community is also battling a growing wave of anti-Asian sentiment spawned by the pandemic.

The AAPI community is well represented in healthcare. Nearly 8.5% of healthcare workers are part of the AAPI community, compared to 6.8% of the population. The community has a rich heritage that has helped shape the history of the U.S. Countless stories and events have enriched America's culture and strengthened its role as a global leader.

May is a time for all Americans to actively recognize the impact the AAPI community has had on society and healthcare. This recognition should be carried throughout the year as well.

On this page, we'll highlight the accomplishments of 16 AAPI nurses who have significantly influenced healthcare and their community.

16 AAPI Nurses Past and Present You Should Know

The contributions of minority groups have historically been largely unrecognized and under-recorded. Yet, for a well-rounded view of nursing and healthcare, it is essential to acknowledge the accomplishments, highlight the resilience, and celebrate the enduring public service of the AAPI community.

We chose the following AAPI nurses who have contributed to nursing through research, education, and patient care.

1. Janejira Justine Chaiyasit

Janejira Justine Chaiyasit is an assistant professor of nursing at Columbia University. She is a certified nurse practitioner in adult-gerontology. She received her bachelor's in nursing, master of science in nursing (MSN), and doctorate in nursing from Columbia University School of Nursing. In addition to her teaching responsibilities, Chaiyasit has a clinical practice. She focuses on disease prevention and management, health promotion, and episodic care.

Her research focuses on anxiety, depression, family planning, and women's health. As a nurse leader, she believes it is necessary to advocate for her patients and the Asian population. She uses her role to talk about discrimination and correct inaccurate information.

An Dinh is a Long Beach, California, resident and is employed through the VA Long Beach Healthcare System. She works on the palliative care team and has been honored with a DAISY Award for the care and compassion she shows her patients.

Despite the frustration and stress of her patients' families, she goes above and beyond what's called for in her job. She graduated from the University of Texas Health Science Center at Houston.

3. Kay Fukuda

Kay Fukuda was a naval cadet nurse who was interned at Manzanar War Relocation Center in Eastern California during World War II. It was one of 10 internment camps where the U.S. incarcerated 110,000 Japanese Americans after the bombing of Pearl Harbor.

Manzanar is now designated as a national historical site and described as an example of injustice.

Little is known about Fukuda, who was photographed by Ansel Adams in 1943 when he was encouraged to visit and photograph the camps. Dorothea Lange had written to Adams about her experience photographing the camps. She had been assigned by the War Relocation Authority to document an upbeat and positive message from the internment camps.

Touched by Lange's words, he gained permission to photograph Manzanar to help show Japanese Americans as hard-working Americans who deserved the respect of other U.S. citizens.

4. Anastacia Giron-Tupas

Anastacia Giron-Tupas was born in Laoag, Ilocos Norte on August 24, 1890. She dedicated her career to advancing nursing in the Philippines and globally. She believed nurses were a powerful tool to improve the general welfare of the population.

Giron-Tupas overcame barriers and modeled traits that are associated with current nursing leadership. She advocated for the nursing profession and supported interdisciplinary education.

She is known as the "Dean of Philippine Nursing." Through her tireless efforts, the University of Pennsylvania School of Public Health Nursing became a premier nursing school. She was responsible for developing the first bachelor of science in nursing (BSN) curriculum.

Giron-Tupas recorded many of the changes to nursing in the Philippines in her book, "History of Nursing in the Philippines." She died in 1972 at age 82.

Li Hong graduated with her MSN in nursing informatics from the University of Texas at Arlington. She was awarded the Florence Nightingale Medal in 2019. She was the only Chinese recipient of the award, which was given to 29 nurses worldwide. The award is given to nurses who demonstrate exemplary service or innovation in public health or nursing education.

She is a fellow with the American Academy of Nursing, with specialty training in disaster relief and public health nursing. She currently is the manager of clinical research at the University of Texas Southwestern Medical Center.

6. Aiko Hamaguchi

Aiko Hamaguchi was a second nurse photographed in 1943 by Ansel Adams in the Manzanar War Relocation Center. She appears on no academic databases, and there is no further biography of her on the Internet.

Under the executive order of President Franklin Roosevelt in 1942, the secretary of war was authorized to relocate and detain Japanese Americans, 60% of whom were American citizens.

There was no push to incarcerate Germans or Italians during the same period, even though the U.S. was also fighting them during WWII.

Families were forced to get rid of their property and private belongings over just a few days before moving to relocation centers. Living conditions were deplorable, and detained healthcare workers were pressed into service to care for those in the camps.

By December 1944 when the internment ended, 1,800 had lost their lives and $400 million in property is estimated to have been lost. To put this in perspective, this would be $6.6 billion in 2022.

Eun-Ok Im has served on the faculty at the University of Pennsylvania, University of Wisconsin-Milwaukee, and University of Texas at Austin before joining Emory University in 2019. She is currently the senior associate dean for research and innovation at Nell Hodgson Woodruff School of Nursing at Emory. She has two master's degrees, one in public health and an MSN from the University of California, San Francisco (UCSF). She later completed her doctor of philosophy (Ph.D.) in nursing from UCSF in 1997.

In January 2020, she became the president of the AAPI Nurses Association. She is gaining national and international recognition as a theorist in international cross-cultural women's health. Im has published over 370 papers and presented at over 320 international and national multidisciplinary conferences.

8. Rose Lim Luey

Rose Lim Luey is a child of Chinese immigrants. She graduated from the Samuel Merritt Hospital School of Nursing in 1951 as one of the first Chinese American students. She raised three children and was honored as Oakland's 1972 Mother of the Year. When her children were grown, she returned to public health nursing, using her bilingual skills to help care for Chinese Americans.

She prioritized her volunteer efforts throughout her career, helping Vietnamese immigrants relocate and providing them healthcare services. She was a founding member of Asian Health Services and volunteered for 20 years with the American Red Cross. In 2017, at the age of 87, she was the first in a series of oral histories from Samuel Merritt University Office of Diversity and Inclusion.

9. Carol Manilay-Robles

Carol Manilay-Robles was nominated and honored with the DAISY Award in 2013. This award is given internationally to nurses who treat their patients and family with care and compassion.

The ABP Family Council nominated Manilay-Robles to recognize her tireless work at the ABP Health Center. They cite her model leadership and patient care. She is on the executive board of the Philippine Nurses Association of Metro DC, where she's held several positions, including treasurer and communications and marketing.

10. Maginia Sajise Morales

Maginia Sajise Morales arrived in the U.S. in 1977 from the Philippines after graduating from nursing school. She enlisted in the Army in 1985 and was commissioned as a first lieutenant. She served four years in a reserve unit before pursuing active duty nursing in 1989.

Her first assignment was on a burn unit in San Antonio, Texas, where she earned her MSN at the same time. Her first overseas deployment was in 1994 with the 95th Combat Support Hospital and later with the 212th Mobile Army Surgical Hospital (MASH).

The 212th MASH unit was assigned to Bosnia, where she served as chief of critical care. After returning to the U.S., she led the intensive care department at William Madigan Army Medical Center and earned the rank of major.

In January 2004, she was deployed to Iraq but returned in February due to illness. She was reassigned to William Beaumont Army Medical Center, where she stayed until retiring in November 2004. She was honored by the Army as a "Veteran of the Day" in March 2019.

11. Mary Frances Oneha

Mary Frances Oneha has served Native Hawaiian communities for over 20 years. She earned her MSN from the University of Washington and was the first Native Hawaiian to earn a Ph.D. Her community-based research focuses on understanding Native Hawaiian health issues.

She joined Waimānalo Health Center in 2012 as the chief executive officer. One of her initiatives has been integrating Native Hawaiian culture throughout the organization.

She also serves on the Institutional Review Board of the Association of Asian Pacific Community Health Organizations. Oneha was recognized in 2013 as the White House AAPI Woman Champion of Change and was an American Academy of Nursing fellow.

12. Donna-Marie Palakiko

Donna-Marie Palakiko, Ph.D., APRN, is a Native Hawaiian nurse. She was the first to be hired in a tenure track at the University of Hawaiʻi at Mānoa's School of Nursing and Dental Hygiene. Palakiko received the 2022 Fulbright Postdoctoral Scholarship from the Australian American Fulbright Commission. She also received a $60,000 grant from the Hawaiʻi Community Foundation's Robert C. Perry Fund.

Palakiko spent more than 20 years as a community health nurse, healthcare administrator, and nurse researcher. Before joining the faculty in 2019, she worked as a researcher. Her focus was on developing lifestyle interventions for Hawaiian and Pacific Island people.

13. Vivian Sanderlin

Vivian Sanderlin is chair of The Philippine Nurses Association of San Diego (PNASD) and leader in the PNASD's COVID-19 Vaccination Task Force. She is one of the growing Filipino leaders who have spoken out during the COVID pandemic.

She was the 42nd president of the PNASD from 2016-2018. She worked to raise the standards of student nurses and focused on community service. Sanderlin has also advocated for the vaccination of the Association's members and strives to support her community.

14. Julita Villaruel Sotejo

Born in 1906, Julita Villaruel Sotejo is credited with developing the model of nursing education used in the Philippines. She graduated nursing school as valedictorian of her class in 1929 and then as valedictorian at Philippine Law School.

She was the principal of the Philippine General Hospital School of Nursing until 1941, when she accepted a scholarship to study at Yale University School of Nursing, among other schools. She graduated with a master's degree in nursing administration from the University of Chicago.

She spoke about racial injustice and advocated for representation in education. She earned a doctorate in law at the age of 85. Sotejo died in 2003 at age 97, having explored the boundaries of nursing and leaving a legacy of education and bold nurses.

15. Zenei Triunfo-Cortez

Zenei Triunfo-Cortez is a registered nurse who is serving as one of three presidents of the National Nurses United (NNU) and the California Nurses Association/National Nurses Organizing Committee. The NNU has more than 175,000 members and is the largest union and professional association of nurses in U.S. history. The organization was founded in 2009 to counter nursing standards and patient care conditions.

Triunfo-Cortez has worked tirelessly to inspire nurses from the Philippines, a critical role during the pandemic when many have faced racist challenges while caring for patients. In her role at the NNU, she has been an outspoken advocate for change in the current healthcare system.

Triunfo-Cortez was honored in 2019 by the AFL-CIO during Asian Pacific American Heritage Month.

16. Yu (Philip) Xu

Yu Xu was also known as Phillip. He was born in 1961 in Zheng Zhou, China, and he arrived in the U.S. in 1991 to complete his Ph.D. in education at the State University of New York in Buffalo. He then attended a community college in Alabama, where he earned his associate in nursing. This was quickly followed by an MSN in community and public health nursing from the University of South Alabama.

From 1999 to his death at age 52 in 2013, he published 56 research reports and peer-reviewed articles on transition, adaptation, and integration of international nurses into the U.S. healthcare system. Before his cancer diagnosis, he directed the Ph.D. program in nursing at the University of Nevada, Las Vegas.

He served as the president of the AAPI Nurses Association from 2012 until his death in 2013.

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16 AAPI Nurses To Know For Asian Pacific American Heritage Month | NurseJournal

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Perseverance and pride mark Asian Pacific American Heritage Month in May as we celebrate the men and women who have stood on the front lines during COVID-19. Unfortunately, the community is also battling a growing wave of anti-Asian sentiment spawned by the pandemic. The AAPI community is well represented in healthcare.

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Hispanic And Latino Nurses You Should Know About

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Hispanic And Latino Nurses You Should Know About

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According to 2020 survey data, 5.6% of registered nurse (RN) respondents reported Hispanic and Latino/a heritage - an increase of 0.3% from 2017. Even so, the nursing workforce continues to follow a disproportionately white trend.

Many influential Hispanic and Latino/a nurses pave the way for future nursing generations through mentorships and direct support for the Latino/a nursing community.

The nursing professionals featured on this page include such trailblazers as the founder of the National Association of Hispanic Nurses (NAHN) and a nurse who created a community for Latina nurses. These individuals and the other nurses highlighted below support their fellow nurses and continue to change the face of the nursing workforce.

How Hispanic Nursing Organizations Support Latino/a Nurses

According to NAHN, socioeconomic factors contribute to the loss of Hispanic nursing students and faculty through attrition. To increase the number of Hispanic and Latino/a nursing professionals, NAHN provides information to high school students about the prerequisite classes they need before nursing school, along with resources to support Latino/a nursing students.

NAHN also profiles Latino/a and Hispanic role models and facilitates the Mentors Connection program, which pairs prospective nurses with experienced nurses who offer career advice, guidance, and support.

Calling for more diversity in the nursing workforce, NAHN supports an increase in Hispanic nurses from the current percentage of 5.6% to 18.5%, which aligns with the current Hispanic and Latino/a population in the United States.

Influential Hispanic and Latino/a Nurses to Know

NAHN regularly profiles Hispanic and Latino/a nurses who seek to increase their representation in the profession. The list below offers a sampling of these influential nurses.

Ildaura Murillo-Rohde, Ph.D., R.N., FAAN

In 1945, Dr. Ildaura Murillo-Rohde moved from Panama to San Antonio, Texas. Upon becoming increasingly aware of a lack of Hispanic nurses, she decided to apply to nursing school. Murillo-Rohde earned her bachelor's degree in psychiatric-mental health nursing at Columbia University, followed by a master's and doctoral degree at New York University.

In 1975, Murillo-Rohde helped found NAHN to promote Hispanic and Latino/a nursing education and service.

Hector Hugo Gonzalez, Ph.D., VR-RN

During the 1960s, Hector Hugo Gonzalez attended nursing school in his home state of Texas. In 1974, he became the nation's first Mexican-American RN to obtain a doctorate.

Throughout his career, Gonzalez continued to break new ground as the first Hispanic district president within the Texas Nursing Association. As chairman of the Department of Nursing Education at San Antonio College, he designed flexible curriculum options for students from underrepresented communities to become licensed RNs.

Henrieta Villaescusa, MPH, RN

Henrieta Villaescusa devoted her career in public health to increasing opportunities for women and Hispanics. Her list of "firsts" includes the first Hispanic nurse appointed Health Administrator of the Department of Health, Education and Welfare and the first Mexican-American Chief Nurse Consultant in the Office of Maternal and Child Health, Bureau of Community Health Services.

After her retirement, Villaescusa assisted the Surgeon General in formulating the Hispanic Health Initiative on the west coast and was appointed to the Task Force on Minority Health during the Reagan administration.

Hilda Ortiz-Morales, NPcs, Ph.D., AAHIVS

After completing her doctorate in healthcare administration, Hilda Ortiz-Morales focused on giving back to her community. She developed a successful program that provides care to patients with HIV at Montefiore Medical Center in the Bronx, New York. Most of her patients are Hispanic and African American, with 90% on Medicaid or Medicare. Ortiz-Morales also teaches and mentors future nurses as an adjunct professor at Herbert H. Lehman College.

Elizabeth Aquino, Ph.D., RN

Elizabeth Aquino has logged a distinguished career as a surgical-trauma intensive care nurse and as an associate professor of nursing at DePaul University in Chicago. Driven by a commitment to helping others, she is currently the president of the American Nurses Association-Illinois, having served as treasurer at NAHN and president of NAHN-Illinois Chapter.

As a strong advocate for more accessible healthcare within underserved groups, Aquina mentors Latino/a nurses and works to increase health services in the Latino/a community.

Martha Salmon, RN

Martha Salmon knew she wanted to pursue nursing from the age of 12 but faced a daunting path to get there. Despite needing to complete a long list of prerequisite classes while raising two children, she finished nursing school and now relays her story to inspire others in the Latino/a community. Salmon started Latina, RN to increase the number of Latino/a nurses by encouraging Latinas to take pride in their heritage and pursue healthcare careers.

Adriana Perez, Ph.D., CRNP, ANP-BC, FAAN, FGSA

Assistant professor of nursing and senior fellow Adriana Perez followed in the footsteps of her grandmother, who worked as a nurse in Mexico. As a postdoctoral fellow, Perez tested and refined a community-based exercise health intervention that addressed the cultural and linguistic needs of older Latinas to increase their physical activity.

Perez has long been a member of NAHN, including as president of the Phoenix Chapter. She currently serves as a diversity consultant for the Center to Champion Nursing in America at AARP.

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Hispanic And Latino Nurses You Should Know About | NurseJournal.org

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According to 2020 survey data, 5.6% of registered nurse (RN) respondents reported Hispanic and Latino/a heritage - an increase of 0.3% from 2017. Even so, the nursing workforce continues to follow a disproportionately white trend. Many influential Hispanic and Latino/a nurses pave the way for future nursing generations through mentorships and direct support for the Latino/a nursing community.

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Initially compiled by Sarah Sophie Flicker, Alyssa Klein (May 2020) and updated by The University Office for Diversity & Inclusion

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'Not Racist' Is Not Enough: Putting In The Work To Be Anti-Racist : Life Kit

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'Not Racist' Is Not Enough: Putting In The Work To Be Anti-Racist : Life Kit

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When the topic of racism comes up, I often think of a billboard in the small town of Harrison, Arkansas.

It was a sign promoting a white supremacist radio station called White Pride Radio. The sign's message, emblazoned next to the picture of a cute-looking white girl with a cute-looking dog, read "It's not racist to [heart] your people."

My takeaway: Even white supremacists don't want to be called racist.

Which might explain why, for people dedicated to fighting racism, simply saying you're "not racist" doesn't feel like quite enough. To effectively defeat systemic racism - racism embedded as normal practice in institutions like education and law enforcement - you've got to be continually working towards equality for all races, striving to undo racism in your mind, your personal environment and the wider world.

In other words, you've got to be anti-racist.

You may know me as NPR's TV critic. But I've also spent years exploring how systemic racism affects media and society. I've written a book about it, called Race-Baiter, and built a TEDx talk around how to talk about race across racial lines. As a Black man who speaks often on these subjects, I find race, racism and anti-racism to be things people think they know but often don't - at least, not as well as they think they do.

As the world continues to sort through a racial and civil rights reckoning kicked off by police killings of Black people like George Floyd and Breonna Taylor, now more than ever, people want to know how to be anti-racist.

After talking to a few experts, I and the good folks at Life Kit have come up with a few suggestions.

Tip #1: Accept that we've all been raised in a society that elevates white culture over others. Being anti-racist will mean first challenging those notions inside yourself.

This was one of the most important takeaways from my conversation with Anneliese A. Singh, who just joined Tulane University as its first Associate Provost for Diversity and Faculty Development. She's also written a workbook on these issues called The Racial Healing Handbook.

"Everyone who lives in the United States kind of learns some form of anti-Black racism," Singh says. "I think we have to ask ourselves that question...How does anti-Black racism live within us?"

Singh calls white supremacy "white body supremacy," a term used by therapist Resmaa Menakem, as a way to emphasize how racism has a visceral, physical impact; elevating white bodies, and bringing trauma to non-white ones.

She suggests some people may even go through a process similar to the stages of grief - especially those who have privilege because of their white or light skin - when they uncover their unconscious bias and realize how extensively systemic racism affects their perspectives.

"I'm going to be in denial if I'm white or have light skin about how white supremacy works," she says. "[We'll move] through that denial into some anger...And then when we go into acceptance, I think then we can really leverage our lives to make a difference."

Tip #2: Learn the history of racism and anti-racism, especially in America, to educate yourself about the complexities of the issues you'll be confronting.

A glance at the 2020 bestseller lists reveals lots of great books on anti-racism, from Ibram X. Kendi's How to Be an Antiracistto Layla Saad's Me and White Supremacy and Robin DiAngelo's White Fragility.

Most of them note that, for white folks, anti-racism involves learning to accept that white people have a racial culture, too. I've said white supremacy's greatest advantage is that white racial culture in America is often treated like it's invisible; not directly talked about among white people, some of whom joke that they have no culture.

Singh says people of color can benefit from similar study and introspection, with a particular focus on identifying and challenging any ideas that may breed colorism or contempt for other non-white groups. She calls this dynamic of elevating whiteness among non-white people, "internalized whiteness."

One important note for white people: When people of color share their experiences with white supremacy, believe them.

"I can't tell you how many people I've seen who claim to be anti-racist and care about building anti-racist organizations," Singh says. "But when people of color speak, they're like, 'Oh, well, they're doing it wrong.' Or 'That's one (person's experience).' You have an opportunity in that moment to believe what that person is saying."

Tip #3: Seek out films and TV shows which will challenge your notions of race and culture and dive in deeply, learning to see anti-racism in new ways.

I'm probably biased, but I've always felt TV shows and films teach us how to dream about what is possible in society and what ought to be. (For example: I insist Morgan Freeman's performance as a Black American president in Deep Impact and Dennis Haysbert's turn as President David Palmer on 24 made it easier for some voters to imagine a Black POTUS when Barack Obama came around.)

So I wasn't that surprised when Justin Simien, creator of the Netflix drama Dear White People, told me viewership for his series jumped 600 percent after George Floyd's death sparked an international dialogue on anti-racism.

Dear White People centers on a group of non-white students at a mostly white, Ivy League college as they negotiate issues of identity, classism, anti-racism vs racism, homophobia and more. One poignant storyline features a young Black student, Reggie Green, who is nearly shot by a campus security guard at a party. Reggie then finds himself haunted by flashbacks of the traumatic event as well-meaning acquaintances attempt to check in on him.

Simien says the scenes with Reggie show, without lecturing the audience, how attempts to ask a Black person about racial trauma can sometimes backfire.

"The whole goal of it is for you to care so deeply about these [characters] that you don't realize you're being taught anything," he adds. "When you see that he had a gun pulled on him and he had this near-death experience, and now for the rest of the school year, everyone's coming up to him asking him, "Are you OK? Is there anything I can do?" You understand how that's not enough."

Simien suggests viewers pass up "feel good" TV shows and films showing indisputably virtuous Black people overcoming racism, often in the Jim Crow South, with help from well-meaning white people (in other words, skip screenings of The Help or .)

Well-made TV shows and films about anti-racism should be messier and much more provocative.

"You should feel challenged in some way by the piece because it's so subversive," Simien says. "[Racism is] ubiquitous and it's systemic and we can't see it...Racism lives in our collective blindspots. That's why it's so pernicious. So, there has to be a moment in the piece where you go, 'Oh! I didn't think about it like that.'"

The goal: to expose yourself to art that cuts through prejudices and stereotypes, allowing you to finally, fully see people of color.

"I had a friend put it this way," Simien says. "'We're inviting people to see us for the first time and it should break your heart that you haven't seen us yet'...That I have to interact with you through a character version of myself because I think you can't handle my daily truth. [That] should break your heart."

Tip #4: Find local organizations involved in anti-racism efforts - preferably led by people of color - and help uplift their voices and ideas.

This tip comes courtesy of Arisha Hatch, the Vice President and Chief of Campaigns at Color of Change - a civil rights organization founded in 2005 following Hurricane Katrina.

She says learning to uplift non-white voices - even those who may disagree with you - is important for white people seeking to be anti-racist.

"Part of being an ally and part of letting go of privilege is, I think, putting yourselves in situations where you may be uncomfortable," Hatch adds. "You may have a different idea, but...you're actively working to support organizers and activists who have been thinking about these systemic problems for generations."

Also, Hatch says to be an effective anti-racist, you must assess your own power - where are the spheres where you can have the most influence?

Beyond the obvious strategy of confronting family and friends who may be racist, consider this: When you sit down at a PTA meeting at your child's school, which parents do you speak with and get to know?

At work, are you considering how procedures or strategies may advantage whiteness, and are you helping to challenge them?

Are you spending money with businesses that are owned by non-white people?

If you or a relative has a rental property, are you seriously considering applications from non-white people?

These are ways you can make a difference in your own environment, where you have power. Remember, anti-racism is about pushing past knowing better and instead actively doing better.

One thing is clear: Pulling all of this off takes a lot of energy and can feel overwhelming. And it doesn't help that one way people perpetuate systemic racism in America is by encouraging others to accept the status quo and reject many anti-racist ideas as too extreme.

But there is no better feeling than really making progress on working to build a better world. And these tips offer great ideas for starting on a long and rewarding road.

Above all, Color of Change's Hatch suggests keeping one, optimistic thing in mind.

"This is what winning looks like and feels like," she says of the current drive toward racial equity in law enforcement, politics, corporate America and elsewhere. "The moral arc of history is on our side and we are getting closer and closer every day to a culture that actually embraces the beauty and creativity of Black people in our lives."
This podcast portion of this story was produced by Audrey Nguyen. We'd love to hear from you. Leave us a voicemail at 202-216-9823 with a greeting, your name, your phone number and a random life tip. It might appear in an upcoming episode. Or send us an email at LifeKit@npr.org.

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'Not Racist' Is Not Enough: Putting In The Work To Be Anti-Racist : Life Kit

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Even white supremacists don't like to be called racist. That's why, NPR's Eric Deggans says, "not racist" doesn't feel like quite enough. In this episode, he walks us through steps to being anti-racist - in other words, ways you can continually strive to undo racism in your world and within yourself.

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Andrea Dalzell, MSN, RN - @theseatedNurse 

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Andrea Dalzell, MSN, RN - @theseatedNurse 

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Black Woman, Survivor, Registered Nurse, Disability Rights Advocate and speaker on a mission to helping people live healthier lives.

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Andrea Dalzell | Healthcare Advocate & Spokeswoman | The Seated Nurse

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Andrea was crowned Ms. Wheelchair New York 2015, and utilized her title and platform, Life, Liberty and the Pursuit of Access, to promote her message and belief that people with disabilities can live a fulfilling life.

As an advocate and activist for the rights of people with disabilities, she's earned many spotlights throughout the years including New Mobility's Person of the Year (2021), Craig H. Neilsen Visionary Prize Winner, an ambassadorship with Urbane Scrubs, and features in United Spinal, Homecare Magazine, Apple's iWatch campaign, The Mighty/Yahoo, Forbes and Nurse Blake.

Thanks to her diverse experience, Andrea has been able to devote her career to helping others with disabilities live healthier lives whether seated or able-bodied.

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Andrea Dalzell | Healthcare Advocate & Spokeswoman | The Seated Nurse

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Andrea was crowned Ms. Wheelchair New York 2015, and utilized her title and platform, Life, Liberty and the Pursuit of Access, to promote her message and belief that people with disabilities can live a fulfilling life.

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Free Article: Rethinking Cultural Competence: Shifting to Cultural Humility

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Free Article: Rethinking Cultural Competence: Shifting to Cultural Humility

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Abstract

Healthcare and social services providers are deemed culturally competent when they offer culturally appropriate care to the populations they serve. While a review of the literature highlights the limited effectiveness of cultural competence training, its value remains largely unchallenged and it is institutionally mandated as a means of decreasing health disparities and improving quality of care. A plethora of trainings are designed to expose providers to different cultures and expand their understanding of the beliefs, values and behavior thus, achieving competence. Although this intention is commendable, training providers in becoming competent in various cultures presents the risk of stereotyping, stigmatizing, and othering patients and can foster implicit racist attitudes and behaviors. Further, by disregarding intersectionality, cultural competence trainings tend to undermine provider recognition that patients inhabit multiple social statuses that potentially shape their beliefs, values and behavior. To address these risks, we propose training providers in cultural humility, that is, an orientation to care that is based on self-reflexivity, appreciation of patients' lay expertise, openness to sharing power with patients, and to continue learning from one's patients. We also briefly discuss our own cultural humility training. Training providers in cultural humility and abandoning the term cultural competence is a long-awaited paradigm shift that must be advanced.

Keywords: Cultural competence, cultural humility, intersectionality, racism, stereotype

Cultural competence is well established in the medical and public health lexicon as a means of attending to the culturally diverse backgrounds of patients, providing person-centered care, and reducing health disparities. The term cultural competence and trainings designed to ensure healthcare and social services providers acquire such competence have existed for decades.1,2 However, it might be time to re-examine both the meaning and connotations of the term and the utility of these trainings, given our advances in understanding the root causes of health disparities. Based on our experience in cultural and structural competence training for the New York statewide workforce caring for youth with serious emotional disturbances, we propose training in cultural humility and abandoning the term competence.

In the US, medical schools, health-related professional associations, and government entities currently mandate staff trainings in cultural competence. Although the format, content, and quality of such trainings vary widely, they all aim to enhance providers' knowledge about the cultures of different social groups-typically defined as racial/ethnic or sexual "minority" groups.1,2 The thinking underlying these trainings is that provider familiarity with cultures other than their own can improve their communication skills and ability to establish effective relationships with patients.3 Providers' recognition that they need to improve their understanding of how best to care for diverse patient populations is laudable and presents an opportunity to improve quality of care and reduce disparities. However, the assumptions behind trainings in cultural competence and the use of the term competence are problematic. As discussed below, seeking cultural competence can contribute to the reproduction of social stereotypes and an imbalance of power between patients and providers. Therefore, we strongly recommend providers undergo training in developing cultural humility and provide a training example we are currently delivering to care managers and peer advocates in New York State.

Our call to deconstruct the meaning of the term cultural competence and rethink the utility of related trainings is based on the semantic and pragmatic social consequences of these trainings, as indicated by both theoretical arguments and assessments of the trainings' limited effectiveness in combating health inequities. Culture is not stagnant, but a changing system of beliefs and values shaped by our interactions with one another, institutions, media and technology, and by the socioeconomic determinants of our lives.5 Yet, the claim that one can become competent in any culture suggests that there is a core set of beliefs and values that remain unchanged and that are shared by all the members of a specific group. This static and totalizing view of culture that connotes a set of immutable ideas embraced by all members of a social group generates a social stereotype.2,3 This stereotype is negative and stigmatizing because it refers to beliefs that likely deviate from the providers' own normative belief system. Cultural competence trainings assume that most US providers are White non-Hispanic, male, heteronormative, and English speaking, and seek to expose them to the cultures of other social groups (eg, Black Americans, Spanish-speaking Latinx, or LGBTQ+ persons).6 Moreover, because of the pervasive health inequities by race and ethnicity, these trainings often focus on familiarizing a prototypical White non-Hispanic provider to communicate with non-White patients who are assumed to embrace common beliefs and experiences solely based on their race and/or ethnicity. This approach contributes to the reproduction of racial and ethnic stereotypes and racism. Providers' application of the stereotypes generated in trainings raises the risk of othering patients, a process of amplifying the "us" versus "them" orientation. Significantly, this in-group/out-group perspective can also contribute to implicitly discriminating against patients, if adopted by providers.2,3

The notion of cultural competence is also challenged by intersectionality which suggests that the beliefs and values a patient brings to the clinical encounter are shaped by the intersection of their different characteristics, such as race, class, gender, and sexual orientation. Trainings that familiarize providers with, for instance, the culture of the patient's racial group will be of limited use, since they cannot elucidate the patient characteristics that are at play in a specific clinical encounter. If providers assume that race or sexual orientation is the master status that overshadows other statuses, they risk essentializing the patient and discrediting their perspective.2,3 Such interactions raise the risk of reproducing the power discrepancy between providers that embody medical expertise and authority and patients that embody lay expertise based on their actual lived experiences.10

The risks and limitations of the cultural competence approach to providing services are also supported by the peer-reviewed literature on the effectiveness of cultural competence trainings and programs. We examined published reports within the past 2 decades, since government entities began mandating trainings in cultural competence in the early 2000s.11 Across studies and time, three overarching findings emerged. First, there is extensive variability in all features of trainings and programs in cultural competence, including in their scope, length, content and mode of delivery. This variability has been associated with the ongoing lack of clarity of what constitutes cultural competence and how it develops and hence, a lack of guidelines on designing and delivering related trainings and programs.

Second, trainings in cultural competence primarily increase provider knowledge, attitudes and skills, but have had little or no effect on patient satisfaction and/or patient health outcomes to decrease disparities.3,12-14 Furthermore, there is extensive heterogeneity in the type of knowledge, attitudes and skills that have been found to improve as a result of cultural competence endeavors. For instance, some trainings improve providers' general understanding of the role of culture in patient-provider relationships, while others improve factual knowledge on disease incidence or traditional cultural practices among specific populations.14 The provider skills that improve through cultural competence range from cross-cultural communication skills (e.g., when serving diverse or non-English speaking patients), to assessing cultural factors in patient provider interactions, to skills to follow treatment plans. With reference to attitudes, many trainings focus on enhancing provider self-confidence or self-efficacy in serving diverse patient populations. This improvement, however, has limited significance, given the lack of data on whether greater provider confidence or efficacy enhances patient satisfaction or outcomes.12,13 On the contrary, we suggest that provider self assessment of their own efficacy and competence as higher post training can detract from their humility, increase their authority, and thus, intensify the power imbalance between providers and patients.

Finally, the extensive heterogeneity of the knowledge and behavioral domains that the cultural competence trainings aim to improve accounts for their equivocal effectiveness identified by reviews spanning the past 20 years.3,12-14 Despite this lack of evidence, the mandatory nature of these trainings amplied by funding by government entities, institutions along the private-public spectrum, and provider professional groups suggests a taken-for-granted significance of these trainings that has continued unchallenged for decades.3

Given the shortcomings of cultural competence trainings, like others, we recommend trainings that foster providers' cultural humility. Cultural humility refers to an orientation towards caring for one's patients that is based on: self-reflexivity and assessment, appreciation of patents' expertise on the social and cultural context of their lives, openness to establishing power-balanced relationships with patients, and a lifelong dedication to learning.2-4,10,15 Cultural humility means admitting that one does not know and is willing to learn from patients about their experiences, while being aware of one's own embeddedness in culture(s). While competence suggests mastery, humility refers to an intrapersonal and interpersonal approach that cultivates person-centered care. Cultural humility training encourages providers to reflect on their own beliefs, values and biases-explicit and implicit-through introspection thus, revealing their own culture's impact on patients.16,17 On an interpersonal level, guiding providers to adopt a person-centered stance, open to and respectful of patients' views, promotes real patient-provider partnerships. Providers' humble disposition counterbalances their authority and by equalizing the patient-provider relationship, it can improve communication and quality of care.

Therefore, cultural humility trainings are process-oriented and aim to enhance providers' capabilities to deliver patient-centered care, while cultural competence trainings are content-oriented and aim to increase providers' knowledge, confidence and self-efficacy in communicating with and treating diverse patients.10 The suggestion to focus on fostering provider awareness, openness and humility through the recognition of their own bias, privilege and the limits of their knowledge and expertise was suggested in a seminal article by Tervalon and Murray-García in 1998.4 Yet, only recently, have researchers and practitioners began to advocate for humility trainings, and most of this work is theoretical.2,6,16,17 In an attempt not to reproduce the limitations of the cultural competence trainings and evaluations, cultural humility scholars have recognized the need for assessing the trainings' effectiveness from both the provider and, more importantly, the patient point of view.15,17 We also add the need for a clear conceptualization and measurement of cultural humility, and advise against the proliferation of similar constructs such as cultural safety, cultural sensitivity and cultural respect.3,16

New York State Cultural and Structural Competence (Humility) Training

To move research and practice forward, we have designed a dual-component training for family peer advocates, youth peer advocates and care managers serving families with children or youth with serious emotional disturbances, that integrated several of the Tervalon and Murray-García principles. Our Cultural and Structural Competence (CSC) training is led by expert facilitators with advanced degrees in the social sciences and/or public health. The 6.5-hour training session is conducted in person and is followed by a one-hour webinar "booster" at 4 weeks to enhance trainees' practice.

In brief, the first training component reviews the Cultural and Linguistically Appropriate Services (CLAS) standards with a focus on the domains of culture, structure and health equity. This lecture- and discussion-based component is designed to provide trainees with a shared language for discussing cultural and structural differences and health disparities. We discuss the significance of adopting the term and orientation of cultural humility instead of cultural competence. We also examine the differences between implicit and explicit bias and include Harvard University's Implicit Association Test (IAT) as a self-reflexivity tool trainees can use that can contribute to humility. This lays the foundation for the novel, second component of our training, the Health Habitus Integration (HHI) training.

The Health Habitus Integration component is theoretically driven and aims to provide trainees with the skills and tools to integrate their insights regarding cultural and social determinants of health into their practice as they support families contending with mental health challenges and as they collaborate with colleagues from diverse backgrounds and disciplines.

The Health Lifestyle Model is the theoretical framework of the training. This model emphasizes the concept of health habitus, that is, our tendencies to care for our emotional, mental and physical wellbeing in ways that are shaped by culture and social structure.18 The model indicates that health habitus, informed by (1) our culture, (2) our place in the social structure, and (3) our choices, shapes our health behavior (e.g., whether and how we communicate with providers) and, over time, becomes a health lifestyle.

To familiarize trainees with the application of the model, we engage them in writing about their own health habitus and participating in a group discussion of how culture, structure and choices shaped trainees' own health habitus and actions. This activity is consonant with the Tervalon and Murray-García's4 principle of "cultivating self awareness and awareness of the perspectives of others" (p. 120) that contributes to trainee and trainer humility.

A didactic phase on conducting in-depth interviews to elicit the family and the youth's health habitus follows. This type of interviewing exemplifies Tervalon and Murray-García's4 suggestion for providers to communicate their respect for "the patient agenda and perspectives" by adopting a "less controlling, less authoritative (interviewing) style" (p. 120). Conceding the power of guiding the communication to the patient, the authors argue, presupposes humility. Ongoing feedback from trainees suggests HHI is generating humility as the trainees discover that many of their prior assumptions (often racial biases) about the families they serve are not supported by information they collect in the interviews. Common racial stereotypes about health beliefs and behaviors are deconstructed through our training activities (eg, interview practice scenarios and role play by diverse trainers). A process and outcomes evaluation of our dual-component training using a mixed-methods approach is currently underway with results forthcoming in 2021.

In summary, we have provided a strong and overdue argument for eliminating the term competence and embracing humility in its place, based on theoretical and peer-reviewed literature. We have also suggested a theoretically-based strategy for training in cultural and structural humility that is currently being evaluated. Although striving to become humble is challenging, claiming that we can achieve competence in any culture is untrue and dangerous. The recent appreciation of implicit bias and intersectionality signals the need to abolish the notion of cultural competence and prioritize the development of humility to begin dismantling racism to address health disparities.

Footnotes

Funding: The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Our cultural humility training was funded by SAMHSA: NYS Youth and Families ACHIEVE SAMHSA 1H79SM063413.

Declaration of conflicting interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Contributed by

Author contributions: H-M L, KP, and CL conceived the idea and co-wrote the article. H-M L and CL also led the training and evaluation of the cultural humility project discussed in the article.

References

5. Patterson O. Taking culture seriously: A framework and an Afro-American illustration. In: Harrison LE, Huntington SP, eds. Culture Matters: How Values Shape Human Progress. Basic Books; 2000: 202-218. [ Google Scholar]

6. Patallo BJ. The multicultural guidelines in practice: cultural humility in clinical training and supervision. Train Educ Prof Psychol. 2019:13:227-232. doi: 10.1037/tep0000253 [[ CrossRef] Google Scholar]

8. McCall L. The complexity of intersectionality. Signs. 2005;30:1771-1800. doi: 10.1086/426800 [[ CrossRef] Google Scholar]

10. Rivera PM, Grauf-Grounds C, ed. Diversity training: an overview. In: Sellers TS, Edwards S, Cheon HS, Macdonald D, Whitney S, Rivera PM, eds. A Practice Beyond Cultural Humility. Routledge; 2020. doi: 10.4324/9780429340901 [[ CrossRef] Google Scholar]

11. Office of Minority Health: National Standards for Culturally and Linguistically Appropriate Services in Health Care. Final Report. US. Department of Health and Human Services; 2001. [ Google Scholar]

15. Hook JN, Davis DE, Owen J, Worthington EL, Jr, Utsey SO. Cultural humility: measuring openness to culturally diverse clients. J Couns Psychol. 2013;60:353-367. [[ PubMed] Google Scholar]

18. Cockerham W. Bourdieu and an Update of Health Lifestyle Theory. Medical Sociology on the Move. Springer; 2013: 127-154. [ Google Scholar]

Articles from Health Services Insights are provided here courtesy of SAGE Publications

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Rethinking Cultural Competence: Shifting to Cultural Humility

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Healthcare and social services providers are deemed culturally competent when they offer culturally appropriate care to the populations they serve. While a review of the literature highlights the limited effectiveness of cultural competence training, its value remains largely unchallenged and it is institutionally mandated as a means of decreasing health disparities and improving quality of care.

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Free Article: Looking through racism in the nurse–patient relationship from the lens of culturally congruent care: A scoping review

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Free Article: Looking through racism in the nurse–patient relationship from the lens of culturally congruent care: A scoping review

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Journal of Advanced Nursing

Abstract

Aim

This review aimed to identify the nature of racism in the nurse-patient relationship and summarize international research findings about it.

Design

A scoping review of the international literature.

Data sources

The search process encompassed three main online databases of PubMed (including MEDLINE), Scopus and Embase, from 2009 until 2021.

Review methods

The scoping review was informed by the Levac et al.'s framework to map the research phenomenon and summarize current empirical research findings. Also, the review findings were reflected in the three‐dimensional puzzle model of culturally congruent care in the discussion section.

Results

The search process led to retrieving 149 articles, of which 10 studies were entered into data analysis and reporting results. They had variations in the research methodology and the context of the nurse-patient relationship. The thematical analysis of the studies' findings led to the development of three categories as follows: bilateral ignition of racism, hidden and manifest consequences of racism and encountering strategies.

Conclusion

Racism threatens patients' and nurses' dignity in the healthcare system. There is a need to develop a framework of action based on the principles of culturally congruent care to eradicate racism from the nurse-patient relationship in the globalized context of healthcare.

Impact

Racism in the nurse-patient relationship has remained a relatively unexplored area of the nursing literature. It hinders efforts to meet patients' and families' needs and increases their dissatisfaction with nursing care. Also, racism from patients towards nurses causes emotional trauma and enhances job‐related stress among nurses. Further research should be conducted on this culturally variant phenomenon. Also, the participation of patients and nurses should be sought to prohibit racism in healthcare settings.

Keywords: care, culture, literature review, nurse-patient relationship, racism

1. INTRODUCTION

According to the American Nurses Association, racism is defined as 'assaults on the human spirit in the form of biases, prejudices and an ideology of superiority that persistently cause moral suffering and perpetuate injustices and inequities' (American Nurses Association, 2021) (P.1). Neoliberalism across the globe has made that racism remains invisible in terms of restructuring social classes, producing race categories and racialization (Ahlberg et al., 2019). Racism as prejudice and discrimination based on individuals' race and skin colour is a common healthcare problem across the globe. Ever increasing demographics, globalization and cultural changes in the healthcare context have attracted the attention of policy makers and international authorities to this phenomenon (George et al., 2015).

1.1. Background

Racism is the main cause of the patient's harm. Those patients who experience racist discriminations often have poor healthcare outcomes and access to health care, and suffer from mental health issues (Stanley et al., 2019). Racism in its common form as implicit racial bias specially negative attitudes towards the patient of colour can be pervasively observed in the relationship between patients and healthcare providers leading to healthcare disparities (Hall et al., 2015; Sim et al., 2021). It can also hinder appropriate and adequate use of health care, following up screening programmes and preventive behaviours, adherence to the therapeutic regimen and trust in healthcare providers (Powell et al., 2019; Pugh et al., 2021; Rhee et al., 2019). Disparity due to racism leads to the development of new disabilities in patients or even can worsen the present one (Rogers et al., 2015).

Nurses are located at the forefront of patient advocacy and they are expected to address inequities in the provision of care to their clients. However, structural racism can be observed in nursing practice (Iheduru‐Anderson et al., 2021; Villarruel & Broome, 2020). The counter racism role of nurses across healthcare settings emphasizes the identification of discriminatory care, and the development of tolerance, respect and empathy models for other healthcare professionals (Willey et al., 2021).

Ethics is one part of the anti‐racism paradigm with solutions that prohibit racist attitudes and behaviours in health care (Ho, 2016). Racism violates ethical practice among healthcare professions specially among nurses who are committed to the provision of equitable care to patients as the main part of social solidarity (Hamed et al., 2020; Weitzel et al., 2020).

The international research mainly has addressed racism towards patients. The occurrence of racist behaviours from patients towards healthcare professionals should be also investigated to create an equitable environment that hinders racism from both sides. It has been stated that black, Asian and minority ethnic nurses receive a different treatment from patients as being racially stereotyped and are considered less powerful in comparison with white nurses (Brathwaite, 2018; Truitt & Snyder, 2019). Patients' prejudicial and discriminative behaviours in terms of rejecting suggested care, verbal abuse and even physical violence have been described by these nurses as very painful and disrespectful behaviours leading to moral distress and reduction in the quality of patient care (Chandrashekar & Jain, 2020; Keshet & Popper‐Giveon, 2018).

Racism in the healthcare system has a long history. The identification of the nature of racism and its manifestations helps develop appropriate strategies for its elimination from the healthcare system (Mateo & Williams, 2021). The development of actions to tackle racism and racial discriminations has been chosen as a high‐level event at the 76th session of the United Nations General Assembly (UNGA) in 2021 (World Health Organization, 2021). Nevertheless, our knowledge of the extent of racism in healthcare systems and how it can be detected and prevented has remained limited. A probable reason is that racism directly influences the identity and rationality of healthcare professionals, which hinders holding discussions on this phenomenon in public discourses (Hamed et al., 2020). Open discussions on the issue of racism within the nursing profession help identify the underlying causes of racism and eradicate it from the healthcare context (Iheduru‐Anderson et al., 2021).

Further research is needed to better define racial, ethnic and cultural factors contributing to racism in healthcare systems and develop strategies that minimize their impacts on patient care (Godlee, 2020; Paradies et al., 2014).

2. THE REVIEW

2.1. Aim/s

Previous reviews of the international literature have taken a general perspective towards racism in the multidisciplinary context of health care (Chen et al., 2021; Sim et al., 2021). None of them have investigated racism in the context of the nurse-patient relationship to articulate its characteristics. Therefore, this review of international literature was undertaken to identify the nature of racism in the context of the nurse-patient relationship and summarize international research findings about it.

2.2. Design

A scoping review was performed. It is a research method by which the breadth of evidence in a field is mapped and the nature of the research phenomenon is identified (Daudt et al., 2013). The findings of scoping reviews can inform planning for future research and policy making (Westphaln et al., 2021).

This scoping review was carried out based on the review framework suggested by Levac et al. (2010) consisting of the following steps: identification of the research question; literature search and retrieving relevant studies; selection of studies; charting; collating, summarizing data and reporting results; consultation (Levac et al., 2010). These review steps were described under subheadings suggested by the journal's author guidelines.

2.3. Search methods

The review question was identified as follows: 'what is the nature of racism in the nurse-patient relationship?' The review question was kept broad enough to identify all aspects of this phenomenon in various caring situations, but it focused on related incidents only within the relationship between nurses and patients. It was also formulated by PICO:

P (Population): patients and nurses; I (Interest): racism, and racist attitudes and behaviours in the nurse-patient relationship; Co (Context): all contexts in healthcare including short‐term, long‐term, acute healthcare settings, child, adult, physical and mental healthcare.

The authors designed the review protocol and agreed on its details (Supporting Information 1). They performed a pilot search on Google Scholar and some specialized databases to identify relevant search keywords and phrases. The search process initially was established using the development of keywords, Medical Subject Headings (MeSH), and thesauruses' entry term that were translated into databases. The Boolean method and truncations with the operators of AND/OR were used to create the search sentence, which was pilot‐tested to ensure of its adequacy for retrieving relevant studies and selection of the most relevant databases for conducting the search.

The search sentence included all variants of terms related to nurse, patient, racism (e.g. racial bias, racial prejudice, racial discrimination, covert racism, racial disparity) and relationship (e.g. communication and interaction) in the context of healthcare. After conducting a pilot search, three main online databases that covered the majority of the peer‐reviewed and scientific international literature on racism in the field of nursing consisting of PubMed (including MEDLINE), Scopus and Embase were chosen for conducting the search. A librarian was also consulted to ensure of the accuracy of the search process.

2.4. Search outcome

Retrieved studies should have met the following inclusion criteria to be included in the review: original and empirical studies (qualitative/quantitative/mixed methods); focused on the phenomenon of racism; the nurse-patient relationship; racism from patients towards nurses and from nurses towards patients; various healthcare contexts such as short‐term, long‐term, acute healthcare settings, child, adult, physical and mental healthcare; being published in English language in scientific peer‐reviewed journals.

The publication date was restricted as from 1 January 2009 until 31 October 2021 to comprehensively access relevant studies. Any article that did not provide empirical data (e.g. reviews, commentaries, letters, conference proceedings, books) and did not overlap the main domains of the review (i.e. nurse, patient, racism) was excluded. The search coverage was enhanced through conducting a manual search inside some reputed journals with the history of publishing relevant studies and cross‐referencing from selected studies' bibliographies and previous reviews. The EndNote software was used for data management.

2.5. Quality appraisal

Risk of Bias assessment and quality appraisal generally are not applicable to scoping reviews. Therefore, all relevant studies were included in the reporting of the review results.

2.6. Data abstraction

To prevent bias, the authors (MV, CFM, GU, KI) independently screened the titles and abstracts of retrieved studies. Also, they independently read the full texts of the studies to make decisions on their inclusion or exclusion based on the pre‐determined eligibility criteria. Discussions were held by the authors to reach agreements on the selection of articles and their inclusion in data analysis and reporting results.

An extraction table was used to chart data, facilitate data importing from the selected studies, and categorize their general characteristics based on the author's name, country, publication year, sample and setting and research design.

2.7. Synthesis

The analytic framework was developed by drawing tables to collate, summarize and compare the studies' findings in relation to the review phenomenon and present an overview of relevant literature's breadth (Levac et al., 2010). Also, the studies' findings were thematically analysed by comparing their similarities and differences to gain a more abstract and at a higher lever insight into racism in the nurse-patient relationship.

The consultation step is optional and aims at the provision of stakeholders' involvement by suggesting complementary references and giving insights beyond those found in the reviewed literature. The sensitivity of the research topic and the requirement to obtain ethical permissions for collecting data from nurses and patients hindered the authors to follow this step. Therefore, it was removed from the review process.

The review findings were reflected to the three‐dimensional puzzle model of culturally congruent care by Leininger and McFarland (2002) via the main aspects of the cultural competence puzzle at the healthcare provider's and patient's levels consisting of 'cultural diversity', 'cultural awareness', 'cultural sensitivity' and 'cultural competence' (Leininger & McFarland, 2002; Schim et al., 2007).

The reason for the selection of culture as the analytical framework in this review lies in its application as the point of reference to the concepts of race and ethnicity. Culture is a dynamic concept, broadly encompasses commonalities and diversities in people and communities, and pervasively influences all aspects of life and healthcare (Schim et al., 2007). This synergy can help heal racism in the healthcare system (Hassen et al., 2021).

The Preferred Reporting Items for Systematic reviews and Meta‐Analyses extension for Scoping Reviews (PRISMA‐ScR) was used to guide this review (Tricco et al., 2018).

3. RESULTS

3.1. Search results and selection of studies

In the search process, 149 studies were retrieved (Table 1 ). Duplicates and irrelevant studies were excluded during title screening and abstract reading via holding discussions between the authors. Therefore, 24 articles underwent full‐text reading and assessment, of which 10 studies were entered into data analysis and reporting results given the inclusion criteria (Figure 1 ).

TABLE 1

Databases from 2009 to 2021

Total in each database

Records after title reading

Records after abstract reading

Records after full‐text reading

3.2. Characteristics of selected studies

The general characteristics of the selected studies have been presented in Table 2 . They were published between 2009 and 2021 indicating the review coverage for more than one decade. Five studies were conducted in the United States (Benkert et al., 2009; Cottingham et al., 2018; Martin et al., 2016; Purtzer & Thomas, 2019; Wheeler et al., 2014), two in Norway (Debesay et al., 2014, 2021), one each in the United Kingdom (Deacon, 2011), Australia (Lyles et al., 2011) and Canada (McFadden & Erikson, 2020).

TABLE 2

Title of study

Journal

Country

Aim

Methods

Sample and setting

The studies mainly used the qualitative design (Cottingham et al., 2018; Deacon, 2011; Debesay et al., 2014, 2021; Martin et al., 2016; McFadden & Erikson, 2020; Purtzer & Thomas, 2019; Wheeler et al., 2014), but two studies used the quantitative design (Benkert et al., 2009; Lyles et al., 2011). They were conducted in hospitals and community healthcare settings and were categorised based on their focuses as follows: patients' trust in nurses in relation to their racial identities (Benkert et al., 2009), nurses' confrontation with the racist expression by patients (Deacon, 2011), patient‐reported racial discrimination and communication with nurses (Lyles et al., 2011), perspectives of internationally educated nurses and American educated nurses about interactions with patients (Wheeler et al., 2014); nurses' experiences of home care provision to ethnic minority patients (Debesay et al., 2014); satisfaction of various racial groups of parents with neonatal nursing care (Martin et al., 2016); experiences of nurses of colour about negotiating with patients (Cottingham et al., 2018); health disparities during the nurse-patient relationship (Purtzer & Thomas, 2019); racializing mothers and breastfeeding (McFadden & Erikson, 2020); nurses' critical encounters with ethnic minority patients (Debesay et al., 2021).

3.3. Racism in the nurse-patient relationship

The thematic analysis of the studies' findings led to the development of three categories: bilateral ignition of racism, hidden and manifest consequences of racism and encountering strategies.

3.3.1. Bilateral ignition of racism

Pervasive racist perspectives and stereotypies among patients and nurses shaped their racist behaviours and negatively impacted the nurse-patient relationship.

Racism in institutional practice and policies also contributed to negative stereotypes. Ethnic minority patients who did not follow institutional guidelines were considered outsiders. They were labelled as clients who could not get integrated into social values, and were subject to racist remarks. Education in terms of hidden curricula and by learning from others when nurses worked in healthcare settings established racist stereotypes and attitudes towards patients (McFadden & Erikson, 2020; Purtzer & Thomas, 2019).

From a micro‐perspective, bias and stereotypical attitudes leading to racist behaviours rooted in nurses' personal perspectives towards ethnic minorities who had limited language proficiencies and substance dependencies, and suffered from mental illness (Debesay et al., 2021; Lyles et al., 2011; McFadden & Erikson, 2020; Purtzer & Thomas, 2019). Instead of assessing patients' cultural and ethnic backgrounds and investigating their cultural identities, nurses guessed on patients' cultural characteristics and needs based on their habits and last names to plan healthcare interventions (McFadden & Erikson, 2020). Failure to follow‐up nurses' health‐related advice, patients' socio‐economic factors and stereotypical attitudes developed by patients themselves towards their own physical and mental in‐capabilities enhanced racial distortions among nurses (McFadden & Erikson, 2020; Purtzer & Thomas, 2019).

Nurses did not consider their position higher than patients in the nurse-patient interaction rounds. Nevertheless, some patients placed nurses at the lowest hierarchy of humanistic relationships and labelled them as subordinates. Patients' perspectives of nurses' ethnicity and cultural backgrounds determined the levels of nurses' competencies to provide care and receive respect. Nursing care was rejected by some patients, because of their personal orientations towards nurses' culture and ethnicity (Cottingham et al., 2018; Wheeler et al., 2014).

3.3.2. Hidden and manifest consequences of racism

Negative consequences of racism in the nurse-patient relationship were reported by both patients and nurses. Working in an environment in which stereotypical and racist attitudes influenced the nurse-patient relationship triggered the feeling of insecurity and uncertainty. Fear of making mistakes and crossing ethnic and cultural boundaries of minorities and the possibility of conflicts between patients' and families' beliefs, and nursing interventions enhanced work‐related stress among nurses (Debesay et al., 2014, 2021). Nurses faced uncertainties with regard to how withhold their own personal prejudices and at the same time provide nursing care according to professional commitments (Debesay et al., 2021; Purtzer & Thomas, 2019).

A negative consequence of nurses' racist behaviours was the development of a negative perspective among patients towards the healthcare system. Racism was generalized to the whole healthcare system rather than taking it as a personal matter in the nurse-patient relationship (Benkert et al., 2009). Consequently, patients displayed disappointment or anger to all nurses and retaliated it, which damaged the sense of justice and pride even among those nurses who did their best to provide equitable care to patients (Debesay et al., 2021).

3.3.3. Encountering strategies

Cultural mistrust as the outcome of racism could be avoided through the development of racial concordance in the nurse-patient relationship. The suggested strategy to achieve concordance was the provision of care by those nurses who had similar cultural and racial backgrounds to those of patients (Benkert et al., 2009; Lyles et al., 2011). Also, cultural understanding through the acknowledgment of patients' culture and learning about their values, ceremonies and traditions, integration of patients' values into nursing care and setting healthcare goals to preserve patients' cultural identity was required. Avoiding the creation of an unpleasant atmosphere in the nurse-patient relationship through not directly questioning patients' cultural characteristics, and balancing between care delivery and cultural rituals such as touching patients and undressing them helped prevent crossing cultural borders and creating the feeling of racism. Moreover, leading ethnic minority patients in healthcare journey and covering the gap between them and the requirements of the healthcare system were the main strategies for patient advocacy (Debesay et al., 2014, 2021; McFadden & Erikson, 2020; Purtzer & Thomas, 2019).

When nurses faced racism from patients, they tried to avoid personalizing racist incidents and made jokes of them to control their anger and defend their own emotional well‐being. They considered such sorts of abuses one part of their daily work life that should be coped with (Cottingham et al., 2018; Deacon, 2011). Given the lack of policies in healthcare settings to manage racism, nurses coped with the situation and rationalized racist behaviours to reduce related emotional burdens. They tried to ignore racism and attributed it to patients' background diseases, age, previous negative life experiences and inability to take the responsibility of their own behaviours. As a confrontation strategy, some nurses reported the racist incident to authorities, used medications to calm patients, applied distraction techniques to patients, asked patients to refrain from being assaultive, and informed patients of their behaviours. In the worst case, some nurses decided to change their workplace (Cottingham et al., 2018; Deacon, 2011; Wheeler et al., 2014).

4. DISCUSSION

This scoping review of the international literature aimed to identify the nature of racism in the nurse-patient relationship and summarize international research findings about it. An overview of the breadth of the international literature on this phenomenon was presented consisting of three categories developed by the authors. Culture is intertwined with the phenomenon of racism and can critically influence the nurse-patient relationship (Crampton et al., 2003). Racism as an individual and systemic prejudice is imprinted in cultural artefacts and discourses (Salter et al., 2017). Racist perspectives, stereotypies and behaviours from patients and nurses can be attributed to cultural bias as the interpretation of situations and others' actions according to own set of personal perspectives, experiences and cultural standards.

Delivering unbiased and individualized care to culturally diverse patients is influenced by nurses' cultural competencies. Also, patients' personal attitudes and perspectives, and balancing the power between nurses and patients in healthcare situations are crucial to the development of an appropriate climate for patient care (Oxelmark et al., 2018; Vaismoradi et al., 2015). Accordingly, the findings of this review were discussed using the main aspects of the cultural competence puzzle consisting of cultural diversity, cultural awareness, cultural sensitivity and cultural competence as the elements of the three‐dimensional puzzle model of culturally congruent care at nurses' and patients' levels (Leininger & McFarland, 2002; Schim et al., 2007). The dimensions of this model have also the capacity to be the part of the patient's participation in the provision of culturally congruent care (Schim et al., 2007). Therefore, our discussion using this model covers racist behaviours from both patients and nurses. A summary of the review findings in connection to the culturally congruent care model has been presented in Figure 2 .

4.1. Cultural diversity

According to the review findings, racist behaviours in the nurse-patient relationship rooted in implicit and power biases demonstrating that the patient and the nurse had a low social position. Stereotypical attitudes were developed towards patients with limited language proficiencies, low socio‐economic conditions and different last names and cultural backgrounds.

Globalization is the cause of cultural diversities in health care. Similarities and differences between cultures in terms of race, ethnicity, nationality and ideology shape humanistic relationships in health care (Schim et al., 2007). The patient's and healthcare provider's cultural contexts are crucial in the development of the therapeutic relationship. The establishment of a constructive relationship between nurses and patients without the acknowledgment of their cultural diversities is impossible (Gopalkrishnan, 2018). Marginalization of ethnicities and minorities in the healthcare system should be avoided and instead their cultural diversities should be acknowledged and respected. All measures should be taken to avoid tensions when contacts between cultures occur. The assessment of cultural diversities is the cornerstone of planning for the provision of culturally congruent care through appropriate exposure to cultural differences and prevention of racism (Schim et al., 2007). Diversities in nurses' cultural backgrounds have been shown to be advantageous for the healthcare system in terms of improving the quality of patient care and healthcare economy (Gomez & Bernet, 2019).

4.2. Cultural awareness

In this review, education had an influence on the development of racism towards patients through hidden curricula and by learning at the workplace. Nurses felt uncertain about how to provide care that was congruent to patients' cultural backgrounds without having stress about crossing patients' cultural boundaries. Those nurses who faced racism from patients often were unable to manage the situation, were emotionally overloaded, and lost their concetration on the provision of care. Similarly, patients' racist behaviours towards nurses were attributed to a lack of understanding of nurses' cultural backgrounds.

Gaining knowledge about and recognition of other cultures help to identify the uniqueness of each culture and commonalities between the cultures. Cultural awareness aims at identifying similarities and differences between cultures in terms of religious rituals, routines, preferences and behaviours. It recognizes interpersonal comfort zones and customizes care to them, and suggest a method by which people can interact with others' cultures in the caring relationship leading to the delivery of culturally sensitive care (Schim et al., 2007).

Cultural awareness often happens in the process of informal nursing education because direct education may not be able to provide sufficient opportunities for nurses to become culturally aware (Hultsjö et al., 2019; Kaihlanen et al., 2019). Raising awareness about caring situations in which misinterpretations may occur help with the detection of underlying causes and finding a counteraction framework by which an equitable communication is made with patients and their satisfaction is preserved (Crawford et al., 2017; Tan & Li, 2016). Comparisons of cultures and discovery of common ethical values in the nursing profession help develop skills for the creation of dialogue between individuals' and facilitate integration to the global nursing context (Leung et al., 2020).

4.3. Cultural sensitivity

In this review, institutional practice and policies contributed to the development of negative stereotypes by which ethnic minority patients who did not follow institutional guidelines were subject to racist behaviours. Cultural sensitivity consists of individuals' attitudes towards others and themselves and understanding others' cultural characteristics. It motivates individuals to be cross‐cultural and acknowledges others' cultural heritages. Judging others' cultures based on own culture is against the principle of cultural sensitivity (Schim et al., 2007). Measures taken in healthcare systems to reduce bias and racism should encompass all types of inequalities among ethnic minorities (Sim et al., 2021). Improving cultural sensitivity enhances cultural intelligence and facilitates understanding the impact of culture on health and diseases. Therefore, the provision of intercultural healthcare based on understanding differences and similarities between cultures leads to the reduction of health inequalities and improvement of healthcare quality (Göl & Erkin, 2019; Yilmaz et al., 2017). Public and social media have important roles to tackle the problem of patients' racist behaviours towards nurses in care situations. They can debate healthcare policies, promote public health behaviours, educate patients and inform them of cultural norms in healthcare settings and engage them in the development of an environment that respects cultural diversities. Improving cultural sensitivity involves an increased focus on human rights. Individuals' equal worth and rights regardless of race, ethnicity, language and religion lay the foundation of human rights (United Nations, 2021).

4.4. Cultural competence

The findings of this review showed that patients could not assert their cultural identities and were dissatisfied with nurses' inappropriate communication style and lack of attention to their needs. Although there was no indication of training to nurses about culturally congruent care in our findings, the main focus of strategies to avoid racism by nurses was to acknowledge the patient culture, behave respectfully and provide compassionate care. This coping strategy supported nurses' personal well‐being and at the same time prevented the creation of negative stereotypes towards patients' cultural backgrounds. It is the demonstration of a series of behaviours and taking related actions indicating that healthcare professionals know how to acknowledge cultural diversities and are aware of and sensitive towards the patient's culture (Schim et al., 2007).

In the context of health care, it is to adapt care and comply skills to patients' needs. Being culturally competent facilitates culturally congruence care in the nurse-patient relationship. Cultural competence for ethnic minorities requires organizational support (Taylor, 2005) and it should include work at the system level (Sharifi et al., 2019). Cultural education and training have been emphasized as mitigating strategies that can reduce racism and bias, and enhance cope with cultural diversities. Cultural competence is an important strategy by which health inequities can be addressed (Horvat et al., 2014). It requires practising self‐reflexivity on routines that cause racism and bringing implicit bias to own conscious (Bradby et al., 2021; Medlock et al., 2017; Olukotun et al., 2018). Training about diversities and being exposed to cultural differences in practical placements can promote cultural competence and consequently interaction with culturally diverse patients (Levey, 2020; McLennon et al., 2019). Promoting cultural competence among healthcare providers prevents healthcare encounters and reduces shame and embarrassment among care receivers (Flynn et al., 2020).

4.5. Limitations and suggestions for future studies

This scoping review provided an overview of international knowledge about racism in the nurse-patient relationship in spite of retrieving a few empirical studies on this important phenomenon. More studies might have been published in languages other than English that could not be included in this review, and should be considered by future researchers. Racism in the nurse-patient relationship has remained a less explored area of nursing research specially regarding racism from patients towards nurses. Therefore, more studies about racism in the context of the nurse-patient relationship and in various healthcare contexts should be conducted to improve our knowledge of this culturally variant phenomenon and devise a general unified strategy for the eradication of racism from the nurse-patient relationship.

5. CONCLUSION

Racism threatens patients' and nurses' dignity in the healthcare system. It hinders efforts to meet patients' and families' needs and increases their dissatisfaction with nursing care leading to the loss of trust in nurses and reduction of quality of care. Also, racism from patients towards nurses causes emotional trauma and enhances job‐related stress among nurses leading to their turnover. Nurses often apply coping strategies to relieve the emotional pressure of racist incidents and protect their own emotional well‐being.

Racism in the globalized context of healthcare should be prevented and nurses' and patients' well‐being and dignity should be preserved. It needs the establishment of acts and legislations that prohibit racist behaviours and enforce their report to healthcare authorities to seek support and prosecute racist people. Also, there is a need to develop a framework of action based on the principles of culturally congruent care to eradicate racism from the nurse-patient relationship in the globalized context of healthcare.

The practical implications of the review findings based on the culturally congruent care model are as follows:

Development of a practical guideline to help nurses and patients acknowledge cultural diversities and promote their awareness and sensitivity towards other cultures;

Improvement of nurses' cultural competence through education and training about how to avoid racism during the provision of care to patients with different cultural backgrounds;

Development of policies and practical strategies to ensure that patients are held responsible for racist behaviours that create a toxic environment for healthcare professionals;

Comparing cultures and removing misperceptions about other cultures through communication and dialogue between nurses and patients;

Rectification of institutional policies contributing to the creation of stereotypies about cultural minorities;

Use of public and social media to inform patients of cultural norms in healthcare settings;

Collaboration between associations supporting the human rights of nurses and patients for the development and implementation of zero‐tolerance and anti‐racism policies;

Emphasis on the equal worth of people and human rights in healthcare settings;

Cultural socialization of nurses through education and training about customizing care to patients' cultural backgrounds, demonstrating respect and providing compassionate care;

Active screening and detection of stereotypes, implicit bias and racist attitudes among nurses through self‐reflexivity.

CONFLICT OF INTEREST

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

AUTHOR CONTRIBUTIONS

MV was involved in review design. MV, CFM, GU and KI were involved in data acquisition, analysis and interpretation for important intellectual content, drafting the manuscript and revising it for intellectual content and giving final approval of the version to be published in the journal.

Notes

Vaismoradi, M. , Fredriksen Moe, C. , Ursin, G. & Ingstad, K. (2022). Looking through racism in the nurse-patient relationship from the lens of culturally congruent care: A scoping review. Journal of Advanced Nursing, 78, 2665-2677. 10.1111/jan.15267 [[ PubMed] [ CrossRef] PMC free article] [ Google Scholar]

Funding information

The authors have received no financial support the research, authorship, and/or publication of this article.

DATA AVAILABILITY STATEMENT

Authors do not want to share the data.

REFERENCES

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Bradby, H. , Hamed, S. , Thapar‐Björkert, S. , & Ahlberg, B. M. (2021). Designing an education intervention for understanding racism in healthcare in Sweden: Development and implementation of anti‐racist strategies through shared knowledge production and evaluation. Scandinavian Journal of Public Health, 14034948211040963. 10.1177/14034948211040963 [[PubMed] [CrossRef] Google Scholar]

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World Health Organization . (2021). WHO at the high‐level session of the 76th UN General Assembly (UNGA). Retrieved November 5, 2021, from. https://www.who.int/news‐room/events/detail/2021/09/14/default‐calendar/who‐at‐the‐high‐level‐session‐of‐the‐76th‐un‐general‐assembly‐(unga)

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Looking through racism in the nurse-patient relationship from the lens of culturally congruent care: A scoping review

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Journal of Advanced Nursing This review aimed to identify the nature of racism in the nurse-patient relationship and summarize international research findings about it. A scoping review of the international literature. The search process encompassed three main online databases of PubMed (including MEDLINE), Scopus and Embase, from 2009 until 2021.

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Publisher apologises for 'racist' text in medical book

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Publisher apologises for 'racist' text in medical book

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In a statement to the BBC the publisher said: "While differences in cultural attitudes towards pain are an important topic in medical programs, we presented this information in an inappropriate manner.

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Publisher apologises for 'racist' text in medical book

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A book detailing how to deliver pain relief to ethnic groups has been removed after criticism on social media

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Racial Discrimination from Patients: Institutional Strategies to Establish Respectful Emergency Department Environments

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Racial Discrimination from Patients: Institutional Strategies to Establish Respectful Emergency Department Environments

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INTRODUCTION

Social identity-based discrimination from patients against healthcare providers is a prevalent and well-documented phenomenon.1⁻3 Numerous studies and essays detail clinicians' experiences of slurs, harassment, and violence from patients based on racial identity.4⁻8 In this essay, we advance arguments about how emergency departments (ED) should respond to interpersonal racism from patients. We use an anthropological definition of race as a socially constructed way of categorizing humans based on perceived physical traits, such as skin and hair color.9 However, race does not have an inherent biological or genetic basis: there is greater physical and genetic variation within racial groups than between them, and racial categories vary across societies.9 Rather, race is assigned in ways that afford privilege, wealth, and power to some, while disadvantaging others.9,10

In this editorial, we focus on interpersonal racism, defined as the expression of racial discrimination between individuals, including racial jokes, harassment, and singling someone out on the basis of race.10 We recognize that racial discrimination can manifest in more subtle ways, such as microaggressions, or commonplace verbal or behavioral exchanges that convey hostility-often unintentionally-toward marginalized groups.11 Given significant variability in healthcare providers' recognition and acceptance of microaggressions as discriminatory,12 our advocacy here focuses on unified institutional responses to interpersonal racism. We are interested in increased discussion about protecting the rights and wellbeing of emergency physicians at the same time that we address patients' medical needs, particularly in our climate of profound political polarization in the United States.

Strategies for Dealing with Racist Patients: the Lens from Acute Care Settings

Biomedical scholarship predominantly advances the individual physician's appeasement, negotiation, and accommodation of racist patients, with a focus on prioritizing and moving forward a patient's medical care.13,14 For example, when a patient declines care from a physician who is a racial minority, hospital staff often seek out another physician to care for the patient.4 When a patient yells racial slurs at physicians or tells them to "go back to their country," the physician is expected to respond to the patient courteously, if at all, in the interest of maintaining professionalism,6 or to re-orient themselves to patient needs and "depersonalize" their experiences.15 These strategies construe acceptance of racism from patients as necessary to maintain the therapeutic relationship and imply that the targets of such abuse should be willing to incur it as part of the inevitable costs of the job. However, as seen in the response to sexual discrimination and harassment and bullying, both in broader society and in the medical profession specifically, attitudes and behaviors that were once accepted as part of the prevailing culture are increasingly and rightfully being denounced.16,17 Recognition of the detrimental effects of sexual discrimination and bullying, including psychological consequences, hindered career advancement, and the effects of burnout and attrition on the profession as a whole, have led organizations such as the Joint Commission on Accreditation of Healthcare Organizations and the National Academies of Sciences, Engineering and Medicine to call for institutional and systemic responses.18,19

Less emphasis has been placed on institutional responses to interpersonal racism in healthcare settings. Williams and Rohrbaugh suggest conceptualizing racist language as verbal assault to underscore traumatic consequences and to trigger reporting of such encounters to administrators, as is done for physical assaults that occur in hospitals.4 They also suggest team debriefing and de-escalation trainings to help cope with disruptive and discriminatory patients.4 Others have advocated for involvement of ethics committees with disruptive and hateful patients.13

Unique aspects of emergency care settings affect the possibilities for individual and institutional responses to interpersonal racism. Prior evidence suggests that workplace violence is more common in EDs than in other clinical settings, yet emergency physicians may feel ill-equipped and unjustified in responding to racist abuse from patients who are experiencing an acute psychiatric crisis, delirium, intoxication, or are otherwise in distress.20 Unlike longitudinal care settings, the ED leaves little time for clinicians to establish a therapeutic relationship with patients, which may further disincentivize confronting racist patients. Emergency physicians also face pressure to appease racist patients due to the Emergency Medical Treatment and Labor Act (EMTALA), which stipulates that all patients who seek care in the ED must receive a medical screening examination and stabilization of an emergency medical condition, regardless of their social identity, ability to pay, or behavior.21 Additionally, time constraints, acuity, and frequent changes in team composition preclude emergency clinicians' abilities to acutely or consistently involve ethics committees, debrief in real time, or find another clinician to care for a racist patient.

Consider the following scenarios:

Scenario

A Black emergency medicine resident begins a primary survey during a trauma resuscitation. The patient, who is alert, shouts racial slurs at the resident, including "[N-word] bitch," and demands another physician. None of the team members present acknowledge the discriminatory behavior and proceed with the rest of the survey.

Scenario

A Sikh attending emergency physician evaluates a young intoxicated male patient cursing at staff from the stretcher. When the patient sees the physician, who wears a turban, he begins yelling, "I don't want to see a foreign doctor! I want to see an American doctor!"

In each case, the physician is emotionally traumatized by the hateful remarks, but may feel morally and legally compelled to evaluate the patient for an emergency medical condition warranting stabilization. If the physician determines that the patient does have an emergency medical condition requiring treatment, then we see three viable, but imperfect, options. First, the physician can continue treating the patient, assuming the patient allows, prioritizing the patient's health needs over the physician's own emotional wellbeing, and despite the likelihood of a poor therapeutic alliance. Second, if not in a single coverage ED, the physician could ask another physician, if available, to care for the patient. Third, the physician can supervise and direct the patient's care through an intermediary-a resident physician, advanced practice provider, nurse, or technician-acknowledging that this could lead to variations in care.

The identity of each physician, encompassing their personal values, experiences, and social and emotional capital, also affects their potential immediate responses. In the first scenario, the trainee, who lacks support from the team, does not have the power to excuse herself from the care of the patient. Furthermore, the trainee may fear repercussions of reporting the incident, such as being seen as too emotionally sensitive, unable to prioritize patients' needs, or stereotyped as an angry minority. In the second scenario, the attending physician may feel compelled to compartmentalize the interaction in the moment and maintain composure as the leader of the care team, particularly if concerned about an emergency medical condition.

These scenarios highlight that no singular prescriptive practice can be recommended for emergency physicians who experience interpersonal racism from patients. These physicians should not be charged with personally responding to these situations if they do not desire to do so. Rather, they would benefit from broader institutional support and anti-racist policies as below.

Suggested Institutional Actions to Establish Respectful Work Environments

We suggest three critical institutional actions that EDs should take to respond to interpersonal racism from patients and establish respectful work environments. First, EDs should establish a patient, visitor, and staff code of conduct. An ED code of conduct should clearly state that discriminatory language and behaviors are not tolerated (see Figure ). The code of conduct should be displayed in view of patients and visitors and be physically and electronically accessible to staff as other policies are. If an individual displays discriminatory language or behaviors, staff should provide a verbal reminder of the code of conduct. If the individual then persists in racist language or behaviors, the care team should assess the individual's ability to be discharged. EMTALA and its mandate originated from the guiding principle to care for indigent and uninsured patients. If a racist and disruptive patient does not have a medical condition requiring emergency stabilization and could otherwise be treated as an outpatient, discharging the patient is acceptable. An individual's right to and need for healthcare must be weighed against a clinician's safety and right to work in an environment free from discrimination. While the First Amendment protects hate speech up until it incites violence,22,23 employers are proscribed by Title VII of the Civil Rights Act (CRA) of 1964 from engaging in employment discrimination practices.24 A code of conduct created and promulgated by a hospital is a measure that can promote an environment that is firmly anti-racist and anti-discrimination.

Second, EDs should establish expectations that staff, as members and representatives of the institution, can and should address discrimination from patients in real time. Immediate responses to racism can be particularly meaningful and supportive if expressed by a bystander, rather than the target.25 A bystander response should ideally both address the inappropriateness of racist behavior and lend support to the target of racism.26 Hospital staff who witness discrimination should explicitly make a statement such as this: "Discrimination is not acceptable in the hospital environment"; or "Racist remarks are not tolerated in our emergency department" (see Table ). Regardless of a patient's or visitor's mental status, staff should remind them of the code of conduct, as some individuals with mild intoxication and psychiatric illness are redirectable.

Table

Situation

Sample language

Strategies employed

Bystander outlines behavioral expectations for patient or visitor

"Racist language is not acceptable in our hospital. Please be respectful."
"I must remind you that our code of conduct outlines that discriminatory language and behavior is not tolerated."
"Racist remarks are not tolerated in our emergency department. Please remember that as we take great care of you."
"We are doing our best to take excellent care of you. Please refrain from making racist statements."

Rely on institutional policy to strengthen position
Take firm but professional approach
Remind patient/family of therapeutic intent

Bystander checks in with target

"I am sorry that happened. It upset me. I wanted to check in on how you are doing."
"I am sorry that happened. Please let me know how I can support you."
"I am sorry that happened. I would like to report this incident to our supervisors, if that is okay with you."

Acknowledge situation, name own feelings without projecting them onto target, offer support

Care team member leads debrief

"Our patient's racist language and behaviors today are not acceptable. I'd like to remind everyone of our code of conduct."

Outline interpersonal racism as not tolerated
Remind staff of institutional policy

Care team member assists with provider transition of care when a physician has experienced interpersonal racism

[to colleague:] "I am sorry about what happened. I am willing to assume care of this patient."
"This patient has been stabilized and it is appropriate for their care to be handed off."
"We can have another provider take care of this patient primarily."
[to trainee:] "I'd like to have another provider take care of this patient primarily. You did nothing wrong, but I don't think it is a positive environment for you to remain in."

Acknowledge situation and offer alternative
Affirm appropriateness of care handoff
Recognize that victims of interpersonal racism, particularly trainees, may not feel empowered to voice a preference to not participate in the care of discriminatory patients

Lending support to the target of discrimination may take the form of an individual check-in with the target, such as, "I'm sorry that happened. How can I support you?" A short staff debrief establishing that interpersonal racism is not acceptable can unify the team and express alliance with the target. While immediate debriefing may not be feasible in all high-volume and high-acuity situations, making the time to do so, even if quickly, contributes to a workplace environment of solidarity. Additionally, the transition of care of a discriminatory patient, who still requires treatment, to another physician is in itself a powerful act. This is fundamentally different than acquiescing to racist patients' demands: the decision ultimately rests with the victim, and the intent is to protect them from further abuse. This can be achieved through a protocol that is disseminated and discussed among the physicians in a group and that can be referenced and activated in real time.

While we acknowledge limitations of such protocols in single-coverage EDs as well as situations where patients lack capacity or have immediately life-threatening illness, leadership should foster a culture that normalizes and promotes this form of support whenever feasible. Establishment of these expectations and guidance on how staff can respond to racism can be offered in the form of an announcement at a staff meeting, an email, or, where resources are available, through formalized bystander training.27 Sample language is outlined in the Table .

Third, EDs should create or link to hospital-wide incident reporting mechanisms. There is a clear precedent for healthcare organizations to implement systemic interventions to prevent and report physical assaults in the workplace.28 Incident reporting, whether to department leadership, human resources, anti-racism committees, and/or institutional centers for diversity and inclusion, could contribute to administrative knowledge about the frequency and scope of racist encounters. Additionally, as immediate staff debriefing may not occur in emergency care settings, reporting mechanisms could facilitate a third party reaching out to and supporting the targeted clinician after a racist encounter.

Patients who commit physical aggression against hospital staff receive flags in their charts, leading to warning notifications upon opening the electronic health record. We suggest implementing similar electronic warning systems for patients who engage in racist verbal aggression. Repeat offenders may have a contract or care plan developed, clearly outlining behavioral expectations when receiving emergency and hospital-based care.

In this essay, we focus on race, recognizing the difficulty and awkwardness of conversations about racism when compared to other forms of social identity-based discrimination. However, our recommendations can just as easily apply to creating institutional support for those marginalized on the basis of other identities, such as gender, sexual orientation, or ability status.

CONCLUSION

Institutional responses to interpersonal racism can empower emergency physicians to address discrimination from patients in real time. Rather than relying solely on targets of racial discrimination to accommodate or directly respond to patients, we advocate for institutional responses to promote respectful and supportive workplace environments.

Footnotes

Section Editor: Mark I. Langdorf, MD, MHPE

Full text available through open access at http://escholarship.org/uc/uciem_westjem

Conflicts of Interest: By the West JEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. No author has professional or financial relationships with any companies that are relevant to this study. There are no conflicts of interest or sources of funding to declare.

REFERENCES

19. Benya FF, Widnall SE, Johnson PA, editors. National Academies of Sciences, Engineering, and Medicine, Policy and Global Affairs, Committee on Women in Science, Engineering, and Medicine, Committee on the Impacts of Sexual Harassment in Academia. Sexual Harassment of Women: Climate, Culture, and Consequences in Academic Sciences, Engineering, and Medicine. National Academies Press; US: 2018. [Accessed January 7, 2021]. Available at: [ http://www.ncbi.nlm.nih.gov/books/NBK507206/ Google Scholar]

Articles from Western Journal of Emergency Medicine are provided here courtesy of The University of California, Irvine

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Racial Discrimination from Patients: Institutional Strategies to Establish Respectful Emergency Department Environments

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Social identity-based discrimination from patients against healthcare providers is a prevalent and well-documented phenomenon.1 - 3 Numerous studies and essays detail clinicians' experiences of slurs, harassment, and violence from patients based on racial identity.4 - 8 In this essay, we advance arguments about how emergency departments (ED) should respond to interpersonal racism from patients.

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I'm not racist, but... - Race & Medicine: Dealing with Racism In Healthcare

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I'm not racist, but... - Race & Medicine: Dealing with Racism In Healthcare

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I'm not racist, but... - Race & Medicine

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Racism Towards Healthcare Professionals In this perspective article from JAMA, a Latinx physician-scientist shares some painful past experiences. There are many articles in which healthcare professionals recount their experiences facing racism from patients, colleagues, teachers, and more. Below are a handful providing different perspectives on these experiences.

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DonQuenick: Black Daisy Award-Winning ICU Nurse Faces Discrimination

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DonQuenick: Black Daisy Award-Winning ICU Nurse Faces Discrimination

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A Black nurse claims she faced crippling racial discrimination at an Aurora hospital that led to her being wrongly prosecuted for manslaughter in the death of an elderly patient.

DonQuenick Joppy, 39, claims in a newly filed federal lawsuit that her colleagues at The Medical Center of Aurora discriminated against her by humiliating her, criticizing her in ways they did not criticize her white peers and denying her opportunities for growth.

She claims a pattern of discrimination by the hospital ultimately caused her to be prosecuted for manslaughter in the death of a 94-year-old patient in 2019. The criminal charges, brought by the Colorado Attorney General's Office, were later dropped at the prosecution's request "in the interest of justice," a motion to dismiss shows.

"It's wild," Joppy said in an interview. "My life has been turned upside down... I never killed anyone. I'm a great nurse."

The Medical Center of Aurora's director of marketing and public relations, Rachel Robinson, denied the allegations in a statement Tuesday.

"The lawsuit that has been filed against The Medical Center of Aurora is without merit and is a tactic by a disgruntled former colleague," the statement read.

Joppy was charged in 2020 with manslaughter, negligent death of an at-risk person and neglect of an at-risk person in the death of a 94-year-old patient in the intensive care unit at The Medical Center of Aurora, a hospital owned by HealthONE, which operates several hospitals in metro Denver.

The criminal charges came more than a year after Joppy was fired over the same patient's death, according to the lawsuit, which claims the hospital's investigation into the man's death was racially biased.

The man died on May 24, 2019, after coming to the hospital with evidence of septic shock and multi-organ failure, according to the complaint. He was put on a ventilator before the man's family decided to move him to the ICU for palliative care, according to the complaint.

The patient came under Joppy's care toward the end of her overnight shift, on a day when the ICU was understaffed, according to the complaint. Joppy stayed two hours past the end of her shift, which ended at 7 a.m., to care for the man. Around 8 a.m., a doctor gave a verbal order for "end of life" measures to another nurse, who delegated the order to Joppy, according to the lawsuit.

Joppy then called a respiratory therapist and followed his instructions for turning off the ventilator. The therapist visited the patient shortly after that and disconnected the ventilator, the complaint claims. The patient then died; his death certificate says he died of natural causes, and specifically of septic shock, the lawsuit says.

After the man's death, a supervising nurse in the ICU raised questions about how the death was handled, according to the complaint. The hospital investigated and found that Joppy acted without a documented order to do so in the patient's chart and did not wait for the respiratory therapist to arrive to assist with the ventilator discontinuation, according to the lawsuit, which says those findings are inaccurate.

The hospital also cited Joppy's choice to stay after the end of her shift as reason for termination, but that's common practice in the hospital, according to the complaint.

The hospital fired Joppy, and then, the lawsuit claims, referred the case to the attorney general's office, which filed the charges against her in November 2020.

The medical center's spokeswoman said in an email that the hospital is required to file certain reports with the Colorado Department of Public Health and Environment, and that the attorney general's office has access to those reports and "made the independent decision to investigate the occurrence involving Ms. Joppy on its own."

"We have the utmost respect for our patients and their family's end of life decisions, and we work hard to honor those decisions," the statement said. "When processes designed to ensure the comfort and dignity of patients are not followed, we take appropriate action, including reporting to the Colorado Department of Health and Environment, as required."

In an email cited in the lawsuit, the hospital's vice president of human resources says the hospital was "partnering" with the attorney general's office on Joppy's case. The lawsuit names that vice president and the hospital's then-director of patient safety as additional defendants.

The attorney general's office requested the charges against Joppy be dropped in September 2021. The criminal charges were filed by summons, so publicly available court records do not detail evidence supporting the accusations against Joppy, and the prosecution's motion to dismiss does not give a reason for the dismissal beyond it being "in the interest of justice."

A spokesman for the attorney general's office was unable to provide more information about the criminal case before this story's deadline. The prosecutor who handled the case, who has since left the office, declined to comment.

Joppy has yet to recover from the ordeal, said her attorney, Jennifer Robinson. Joppy has stopped working as a nurse - although her license is active - and is in an unstable housing situation.

"I took this case on because I thought it was particularly egregious that they would do this to someone's life," Jennifer Robinson said. "She's pretty much homeless now and hasn't recovered since all of this happened. Who is going to hire a nurse who has manslaughter charges against her, even if they are dropped? It's just not cool to treat people this way."

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Black nurse claims racial discrimination at Aurora hospital led to unfounded manslaughter charge

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A Black nurse claims she faced crippling racial discrimination at an Aurora hospital that led to her being wrongly prosecuted for manslaughter in the death of an elderly patient. DonQuenick Joppy, 39, claims in a newly filed federal lawsuit that her colleagues at The Medical Center of Aurora discriminated against her by humiliating her, criticizing her in ways they did not criticize her white peers and denying her opportunities for growth.

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Dawn Wooten - Americans Who Tell The Truth

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Dawn Wooten knew that what she was seeing was wrong. In the early spring of 2020, as the deadly coronavirus sent the world into lockdown, the management team at her place of employment—the Irwin County Detention Center in Georgia—seemed intent on ignoring the threat. The facility’s leadership failed…

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Hispanic Nurses’ Experiences of Bias in the Workplace

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Hispanic Nurses’ Experiences of Bias in the Workplace

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Hispanic Nurses’ Experiences of Bias in the Workplace

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We recognize the history of our education system, including and not limited to the history of the creation of student activities and groups, and the need to commit ourselves, as a predominantly White community, to self-reflect and act to build a better, more inclusive, and equitable environment.

As the advisor of Hastings' student groups and Student Association, I recognize the privilege I possess as a White, cisgender-passing woman, as well as my need to continue to educate myself to be a stronger ally and advocate for our students. I am committed to using my platforms, voice, and resources to amplify the experiences, needs, and concerns of marginalized communities, and call upon the rest of our community--students and employees--to join me in creating a culture of respect.

In addition to the action steps being taken by the Office of Student Engagement, we challenge you, our student leaders, to actively stand up against racism and oppression in your groups, on our campus, and in the greater world. The movement for justice, equity, and accountability must begin here at home as we examine our own practices and impact. It is important to recognize that our educational and social systems were originally founded in a segregated world for the benefit of predominantly White, wealthy students. However, that is not the way you or your groups should function today. Resist the urge to sit complacently on the sidelines or to assume that systemic oppression does not impact you or your communities. Call out oppression framed as tradition. Engage in honest reflection, reexamine your group's practices, challenge old ways of thinking, begin the process of self-education, and consider ways your groups can help to build a more just world.

If you need any help, additional resources, support, or a place to talk, vent, or exist, the Office of Student Activities practices an open door policy--and there are snacks.

With continuous support and respect,

Alyssa Roush (she/they) | Student Activities Coordinator | alyssa.roush@hastings.edu
Office Location: Hazelrigg Student Union, behind Campus Connect Desk

Civic engagement means using your knowledge, skills, and values to create change in your communities and addressing public concerns. The Office of Student Activities is here to help you do that. Below is a non-exhaustive list of ways to be civically engaged and aligned with the College and Office's core values.

Volunteer with or begin philanthropic partnerships with organizations that support People of Color and the Black community such as:

Ensure your governing documents, policies, practices, and programs are accommodating for all members regardless of socioeconomic status, race, religion, etc. to ensure access and involvement

Encourage your governing councils, inter/national organizations, and institution to implement sustainable policies regarding diversity, equity, and inclusion

Be an advocate and active bystander

Call out racist comments and jokes

Ensure marginalized members' voices are represented during decision-making

Lead by example-attend educational events and encourage others to as well

Hold yourself and each other accountable for upholding the values of your group, your community, and the College

Make sure your actions are congruent with your words

Promote respectful treatment of all members, students, and community members at large

Allow for a safe, judgment-free, open discussion forum for members to understand and discuss White privilege and its impacts on your chapter, the community, and the campus

Practice compassion, understanding, and empathy

Collaborate with campus leaders and multicultural organizations to promote inclusion, education, and amplification of diverse perspectives on campus

Implement educational training regarding implicit bias, diversity, power and privilege, etc.

Get involved in the campus and local communities. . Join boards, commissions, and/or committees. Run for a leadership position to help create change. Sign petitions. Attend or help organize protests. Support local businesses, especially those owned by BIPOC and other underserved communities.

To better understand the issues before us, we are going to have to take the initiative to learn new things. Reject the desire to ask Black people, Indigenous people, or People of Color (BIPOC) to explain racism for you-find resources created by BIPOC to help educate yourself. Some non-exhaustive educational resources are listed below.

Why Are All the Black Kids Sitting Together in the Cafeteria (Beverly Tatum)

I'm Still Here (Austin Channing Brown)

Whistling Vivaldi (Claude Steel)

White Awake (Daniel Hill)

How to be An Antiracist (Ibram Kendi)

The Fire Next Time (James Baldwin)

White Fragility (Robin DiAngelo)

Me and White Supremacy (Layla F. Saad)

The New Jim Crow: Mass Incarceration in the Age of Colorblindness (Michelle Alexander)

Just Mercy (Bryan Stevenson)

The Hate U Give (Angie Thomas)

We recognize and celebrate the intersecting identities in our community. We are here to help you in the best ways that we can. Below are some more non-exhaustive resource lists catered toward specific identities.

Included are additional resources to support BIPOC and their allies:

For the Christian community:

For the Jewish community:

For the Islamic community:

For the Buddhist community:

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Student Activities - Anti-Racism Resources

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The Office of Student Activities stands in solidarity with Black, Indigenous, People of Color (BIPOC) and detests police brutality, systemic racism, discrimination, and oppression. We strive to create a more inclusive and equitable environment for the entire Hastings College community and

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Scholarly Article: Discourse of race and racism in nursing: An integrative review of literature

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Scholarly Article: Discourse of race and racism in nursing: An integrative review of literature

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Scholarly Article: Rejecting the myth of equal opportunity: an agenda to eliminate racism in nursing education in the United States

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Scholarly Article: Rejecting the myth of equal opportunity: an agenda to eliminate racism in nursing education in the United States

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White dominance in nursing education: A target for anti-racist efforts

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White dominance in nursing education: A target for anti-racist efforts

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Trends in racial and ethnic demographics of the nursing workforce: 2000 to 2015

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Trends in racial and ethnic demographics of the nursing workforce: 2000 to 2015

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The impact of Whiteness on the education of nurses

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The impact of Whiteness on the education of nurses

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The nursing workforce of North Carolina: Challenges and opportunities

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The nursing workforce of North Carolina: Challenges and opportunities

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Associate degree nursing: entry into practice—link to the future

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Associate degree nursing: entry into practice—link to the future

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Scholarly Article: The Relevance of Associate Degree Nursing Education: Past, Present, Future

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Scholarly Article: The Relevance of Associate Degree Nursing Education: Past, Present, Future

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Associate degree nursing education remains a vital, compelling choice for students interested in entering the nursing profession. With its rich heritage and contemporary efficacy, associate degree nursing continues to positively impact the registered nursing population in the United States.

For fifty years, associate degree nursing programs have been a subject of curiosity, controversy, and conviction. Their growth from seven pilot schools to more than 800 programs nationwide, represents a phenomenal picture of success. Graduates of associate degree nursing programs represent almost 60% of the entry level graduates each year. As reported in The Registered Nurse Population, March 2000, Findings from the National Sample Survey of Registered Nurses ( Spratley, Johnson, Sochalski, Fritz, & Spencer, 2001), of the nearly 2.7 million registered nurses in the United States, 34% report the associate degree as their highest education degree. More than 40% of the RN population received their basic nursing education in an associate degree program ( Spratley et al., 2001).

The concept of preparing associate degree nursing graduates was developed during a time in our country that has marked similarities to today.

World War II was just ending, and despite earlier predictions, not all nurses who had been in military or civilian practice were remaining in practice. A nursing shortage was present and evolving, affected by both a decreased supply and an increased demand. Haase ( 1990) reported two major concerns that were repeatedly questioned, specifically, "why weren't more students choosing nursing as a career?", and "why weren't more licensed nurses continuing in active service after the first few years following graduation?" (p.11). The increased demand was influenced greatly by three developments: advances in medical sciences, improved medical facilities, and increased numbers of health care insurance participants ( Haase, 1990).

Several forces served as catalysts for the development of associate degree nursing education programs: interest and growth of junior colleges, federal involvement in funding and spending, consumer concern and support, and professional responsibility and accountability. As early as 1945, The American Association of Junior Colleges (AAJC), which is now recognized as the American Association of Community Colleges (AACC), during a meeting with the U. S. Office of Education, discussed the possibility of including nursing in junior college curricula ( Haase, 1990). The involvement and support of AAJC/AACC continued through the early years of the development of associate degree nursing education and continue to date. Much of the evolvement and growth of associate degree nursing has matched the evolvement and growth of junior and community colleges.

The federal government impacted nursing education in numerous ways. Funding for nursing directly affected the number of nursing graduates. The Bolton Act of 1943 funded the costs of nursing education, and provided a living stipend. During these funding periods, annual graduation rates increased conspicuously. Unfortunately, this funding source ended in 1948. Without federal funding, the number of nursing graduates fell significantly. During this time, several attempts to legislate federal monies for nursing were defeated. Legislators, nurses, physicians, and health care administrators could not overcome reported concerns about how monies would be appropriated and spent. However, the federal government was spending an increasing percentage of the gross national product on health care ( Haase, 1990).

Several consumer groups and foundations had a profound impact on associate degree nursing. Even the monies used to launch the pilot project for implementing associate degree nursing programs were given by an anonymous group of women. The Carnegie Foundation funded the research of Dr. Esther Lucile Brown, who published the study, Nursing for the Future, better known as the Brown Report. Although this report did not directly promote associate degree nursing programs, it did suggest that nursing take place in the nation's colleges and universities, instead of in hospital-based programs ( Haase, 1990).

The W. K. Kellogg Foundation has been instrumental in several projects affecting the development and success of associate degree nursing education. Monies have been given to fund graduate programs to prepare associate degree nursing educators, continuing education for associate degree educators, consultant services, and various pilot projects ( Haase, 1990). Some of the projects Kellogg has implemented over the past fifty years have included foci on teacher education, demonstration sites, education and service partnerships, and geriatric nursing curricula.

The shortage of nurses, the interest in moving nursing education to colleges and universities, and the desire to find more efficient ways to educate nurses were common concerns of nursing educators and administrators.

In January 1952, a project was initiated that introduced two-year associate degree nursing programs. This project, know as the Cooperative Research Project in Junior and Community College Education for Nursing, was based at Teachers College, Columbia University. The project director was Dr. Mildred Montag, whose dissertation, Education for Nursing Technicians, promoted a research-based plan to create and test a model for the new nursing degree. The two main purposes for the project were defining the new worker and designing the education program for the new worker ( Haase, 1990, p. 26-27).

The curriculum design reflected approximately half general education courses and half nursing courses. The concept of nursing was patient-centered, not disease centered. Nursing courses were based on broader structures, e.g., adult nursing, maternal and child nursing, etc. Fundamental concepts were taught early in the programs, which were later built on, with complex concepts taught in the second year ( Haase, 1990, p. 36).

Clinical experiences reflected great differences, too. Community facilities were added to hospital-based experiences. Clinical sites included "day nurseries, nursing homes, specialized hospitals, health clinics, family planning agencies, public schools, physicians' offices, and self-help groups" ( Haase, 1990, p. 37). Interestingly, these clinical sites mirror those of many community college programs today, who have developed "new" curricula.

The student populations in the pilot programs differed from student populations in traditional nursing programs. The programs attracted older students, many of whom were married, widowed, or separated. Traditional hospital-based programs had not allowed older or married students. A higher number of male students were also represented in the pilot associate degree nursing programs ( Haase, 1990, p. 38). Many of the population dynamics from this period continue to date.

Evaluation of the initial pilot schools reflected the following conclusions, as reported by Dr. Montag and cited by Haase ( 1990, p. 40).

graduates were able to pass the licensing examinations;

graduates were able to carry out the functions of the staff nurse;

the programs attracted students;

the program did become an integral part of the community college;

the college was able to finance the nursing program just as it did other programs.

The success of the early programs became a stimulus for growth. Within 25 years, the number of associate degree nursing programs grew from seven to nearly 700. And today, fifty years after their introduction, there are more than 800 associate degree nursing programs in the nation.

Controversy has marked the associate degree nursing education since its inception. An exhaustive review of the controversies will not be included, but highlights of controversial issues will be examined.

In 1960, the American Nurses Association (ANA) first introduced promotion of the baccalaureate program to become the basic educational foundation for professional nursing. This authenticated earlier support from ANA and other groups for moving nursing education to colleges and universities. However, this took a further step by promoting the baccalaureate graduate as the professional nurse. Quickly, dissension occurred among educators from all program types; associate degree, diploma, and baccalaureate. That controversy, regarding the title of professional nurse, persists today ( Haase, 1990).

Controversy in nursing was not limited to entry level issues. Nursing organizations had gone through mergers, divisions, and disagreements over organizational roles. However, in 1965, both the ANA and the National League for Nursing (NLN) took stands on the future of nursing education. The ANA document, known as "the Position Paper" described the baccalaureate degree as the minimum preparation for beginning professional practice for the present time. The NLN document, Resolution 5, was more cautious, but called for examination of the differentiated functions of the different entry programs ( Haase, 1990). These position statements again proved to be controversial and divisive. The themes from these two documents highlight two of the most frequent themes of contention: professional nursing versus technical nursing, and differentiated nursing practice.

In 1982, the National League for Nursing (NLN) approved the document Position Statement on Nursing Roles-Scope and Preparation, which stated that "professional nursing practice requires the minimum of a baccalaureate degree with a major in nursing. Preparation for technical nursing practice requires an associate degree or a diploma in nursing" ( Kaiser, 1983, p. 18). Many members of the NLN education councils for associate degree nursing and diploma nursing did not support the position statement.

In the NLN publication, The Associate Degree Nurse: Technical or Professional?, ( Kaiser, 1983) three papers were included that were presented during a forum at the American Association of Community and Junior College (AACJC) annual meeting in 1983. The forum was established to respond to the 1982 NLN position statement. Dr. Mildred Montag discussed the historical use of the term technical nurse. Dr. Montag described how the choice of technical nurse was influenced by the nursing functions that the new nurse would be taught, and the fact that community and junior colleges were preparing other technical workers ( Kaiser, 1983).

Representing AACJC, Dr. Theodore Tilton expressed the premise that although the original design might have been for associate degree graduates to have different roles, the fact was they were being licensed as registered nurses in all states. Dr. Tilton emphasized the contributions that associate degree nursing had made in thirty years: the vast numbers of graduates, the large number of programs, the influence of change on the nursing population, with greater numbers of older students, with a higher representation of minority groups and males. For certain, the majority of Dr. Tilton's comments were in opposition to the 1982 NLN position statement ( Kaiser, 1983).

The third paper presented comments from an associate degree nursing educator, Celia L Hartley. Ms. Hartley supported the 1982 NLN position statement noting that: NLN represented all four types of basic nursing education; the position statement did not propose change in licensure; NLN supported educational mobility; and NLN had supported projects to define competencies of all graduates. Acknowledging associate degree educators' lack of acceptance of the term "technical," Ms. Hartley expressed the discomfort between the contrast of technical to professional. Speaking to the word "professional," Ms. Hartley said, "it is unfortunate that nursing has chosen the word to label the graduates of four-year programs and their skills. We don't hear medicine, law, or dentistry talk about professional doctors or professional attorneys" ( Kaiser, 1983, p. 14).

With the stronger position statement from the National League for Nursing and funding from ANA to implement the ANA position statement, many associate degree educators became disenfranchised with the two leading nursing organizations. In 1986, the National Organization for the Advancement of Associate Degree Nursing was established. This organization later became known as the National Organization for Associate Degree Nursing (N-OADN). N-OADN is the only national professional nursing organization whose goals and strategic plan are focused on associate degree nursing education and maintaining licensure for graduates from associate degree nursing programs:

N-OADN's Position Statement in Support of Associate Degree Nursing as Preparation for the Entry-Level Registered Nurse ( National Organization for Associate Degree Nursing [N- OADN], 1998) reports:

Associate Degree Nursing (ADN) education provides a dynamic pathway for entry into registered nursing (RN) practice. It offers accessible, affordable, quality instruction to a diverse population. Initiated as a research project in response to societal needs, ADN education is continually evolving to reflect local community needs and current health care trends. ADN graduates are prepared to function in multiple health care settings, including community practice sites.

Graduates of ADN programs possess a core of nursing knowledge common to all nursing education routes. They have continuously demonstrated their competency for safe practice through National Council Licensure Examination for Registered Nurses (NCLEX-RN®) pass rates. These nurses provide a stable workforce within the community. The majority of ADN graduates are adult learners who are already established as an integral part of the community in which they live. They exhibit a commitment to lifelong learning through continuing education offerings, certification credentialing, and continued formal education.

Nurses prepared at the ADN level are caring, competent, and committed health care providers who fill a vital need in local communities. Accordingly, the National Organization for Associate Degree Nursing supports ADN preparation as the entry level into registered nursing ( N-OADN, 1998, p.1).

Differentiated nursing practice is another concept that has been interpreted differently by various nursing groups. Most constituencies believe there are varying roles required for nursing practice. Points of difference usually involve the importance formal education holds on the ability of the nurse to assume different nursing roles. Some differentiated nursing practice models include formal education, lifelong experiences, work experience, and specialty certification as mechanisms for maintaining or assuming new roles. Many state and national models have been identified, but none of them have been implemented at a national level.

In 1995, A Model for Differentiated Nursing Practice was published ( American Association of Colleges of Nursing [AACN], 1995). The American Association of Colleges of Nursing and the American Organization of Nurse Executives began the work that resulted in this publication, which later included associate degree nursing education and community and long-term care delivery organizations in the task force work. In a letter acknowledging the Associate Degree Nursing Perspective, Dr. Carol Singer, the president of N-OADN at the time of the task force work stated:

N-OADN has previously acknowledged the need for and continues to support health care reform in the United States but recognizes the new and different challenges it will bring to nurses as well as changes in their practice roles. To meet the demands of health care reform, we believe that it is critically important that approaches be used that recognize that each nurse has value and purpose, and as such will play an important role in it. In addition, the basic premises of this project, built upon the essence of nursing as a series of integrated values, enhances its potential acceptance as a model far different from the traditional, incremental, competency-based models of the past ( AACN, 1995, p. v.).

Two years later, N-OADN ( 1997) published a resolution on differentiated nursing practice that acknowledged the contribution of experience, competence, and life long learning in defining the roles and functions of registered nursing practice. The resolution acknowledged N-OADN's support of the registered nurse's involvement in developing competencies of roles in varied practice environments, and support of practice models that value registered nurses and their practice. The resolution also challenged N-OADN to serve as an advocate for registered nurses, so that the nurses would have the opportunity to assume roles appropriate to their capabilities and experience ( National Organization for Associate Degree Nursing [N-OADN], 1997).

With such diverse opinions about entry level registered nursing practice and practice models, it is not surprising that the various nursing organizations today continue to find obstacles when defining the future of registered nursing practice. Many previous efforts have been unsuccessful because decisions were made without significant representation of all program types. Speaking of associate degree nursing, Kaiser commented, "Decisions about nursing must heed the voice of this large and significant group, who are making an important contribution to health care" ( Kaiser, 1983, p. iv.). At the state, regional, and national level, integration of associate degree nursing educators and nurses in practice into groups who are designing a vision for nursing practice is essential.

Demographics related to associate degree nursing education and practice demonstrate the impact that associate degree nursing continues to make on the U. S. registered nursing population and provide information for defining future implications. The most recent national statistics show that fewer women are choosing nursing, and the number of men has not significantly changed. Minority representation is better, but does not nearly represent the U.S. population. There are fewer graduates with lower pass rates. The nursing population is aging. The effect associate degree nursing has on each of these factors will be examined.

As mentioned in the introductory comments, of the nearly 2.7 million registered nurses in practice, 40.3% of registered nurses reported completing an associate degree program and 34% of registered nurses reported their highest education degree as associate degree. Registered Nurses who obtained their basic education in diploma programs and baccalaureate programs are 30% and 29% respectively. Graduates from associate degree nursing programs also provide a source for baccalaureate and masters programs: 15.5% of registered nurses initially prepared in an associate degree nursing program reported completing additional nursing or nursing related degrees ( Spratley et al., 2001, pp. 6-7).

Graduates of associate degree nursing programs represent almost 60% of the RN candidate pool. (National Council of State Boards of Nursing [NCSBN], 2000). During the past five years, the NCLEX-RN Candidate pool for associate degree graduates has decreased by 26%. This is the same decrease in percentage as for all candidates. From 1995 to 2000, the number of graduates of all program types was reduced from 96,610 to 71,475, and the number of graduates of associate degree programs from 59,908 to 42,665. Similarly, and mirroring the national pattern, graduates of associate degree programs have seen an 8% decline in first time pass rates over the past five years, moving from 91% to 83.8% ( NCSBN, 1995, 2000).

Associate Degree Nursing reflects a higher representation of minorities. Graduates of associate nursing programs are represented by 21.3% individuals from minority groups, and 10.7 % are male. This corresponds with 12.3% minorities and 5.4% males in the total registered nursing population ( Spratley et al, 2001). Table 1 demonstrates the breakdown of minority groups for associate degree nursing graduates compared to the total RN population.

The average age of registered nurses employed in nursing is 43.3. The average age at graduation of associate degree nursing graduates is 33.2, almost three years higher than all basic education programs. The age for Baccalaureate and Diploma graduates is 27.5 and 30.8, respectively. Over the past twenty years, nurses who are less than forty years of age have changed from representing almost half of the nursing population in 1980 to representing less than a third of the nursing population in 2000 ( Spratley et al, 2001).

Associate degree nursing education continues to present a compelling option for individuals interested in the nursing profession.

Numerous characteristics of associate degree nursing programs attract prospective students: lower tuition rates, geographic locations, completion time, reputation of graduates, dynamic curricula, and effective faculties. Unfortunately, these qualities are promoted primarily by word of mouth. If there is any self-criticism of associate degree nursing, it would involve the lack of consistent efforts to publish information about associate degree nursing education and practice. Quite often, decisions are made about associate degree nursing, based on outdated or a lack of information. There are exemplar programs across the nation that can serve as benchmarks for excellence in such areas as retention, creative teaching, alternative clinical sources, curriculum process, and student satisfaction.

Comparison of Associate Degree Nursing Population Demographics to Total RN Population

Note: Data from The Registered Nurse Population, March 2000, Findings from the National Sample Survey of Registered Nurses by Spratley, E., Johnson, A., Sochalski, J., Fritz, M., and Spencer, W. ( 2001), published by U.S. Department of Health and Human Services.

In N-OADN's Policy Statement on the Nursing Shortage ( 2001), the following statement summarizes the commitment of associate degree educators to impact the current shortage in nursing:

The current nursing shortage is most acute in hospitals; the initial setting for practice for the majority of registered nursing graduates. Therefore, associate degree nursing educators continue to be committed to provide educational programs that produce the nurses necessary to meet the demands of the nursing shortage.

Associate degree programs provide a sound foundation for the delivery of safe client care in the current complex health care delivery system. The programs are a reasonable investment of time and money for the student, allowing for licensure and employment in two years from the time of admission to the nursing program. Evidence of this can be seen by: the number of students who seek associate degrees in nursing; the strong passage rate on the NCLEX-RN exam by associate degree nursing graduates, which exceeds or equals that of other graduates; and the success of the associate degree graduates in nursing practice. ( N-OADN, 2001).

Partnerships between education and practice should be expanded to develop creative extern, intern, and residency programs, for students, graduates, and nurses in practice. Lifelong learning to promote continued competence and enhanced knowledge should continue to be emphasized in associate degree nursing programs. Intensive efforts should be made to collaborate with other organizations to create and promote national models for education mobility to baccalaureate and master's programs.

Associate degree nursing educators should also continue to be involved in recruitment efforts. Several national initiatives have already made great strides in promoting the image of the registered nurse. The collaborations among all program types, as well as between education, practice, and the public, are producing the most effective recruitment endeavors. Implementing recruitment activities at the local level remains vital, including age groups from elementary schools to adults, with emphasis on minority populations.

The future of nursing has been the subject of many groups over the past fifty years. In recent years, these groups have attempted to be inclusive of the various education program types, and multiple practice groups. Unfortunately, through timing, degree of involvement, or number of participants, associate degree nursing has not enjoyed equal inclusion in many of these endeavors. Participation involves risks, but is essential if a group or organization is to have a voice in what the future of nursing will be. For associate degree nursing, it is our responsibility to articulate the educational outcomes of our programs, and the competencies of our graduates.

Models of nursing practice that compliment the efficacy of associate degree nursing education must be identified or designed.

All efforts to define the future of nursing should center on the needs of the communities we serve. Models of nursing practice should reflect the ability of the nurse to meet those identified needs. Although there is no current consensus on the future of nursing, or future models of nursing practice, very few could disagree with the words of Dr. Mildred Montag,

The real concern of nursing, of nurse educators and nursing service administrators alike, is that practitioners of nursing be prepared and employed in a manner that promotes the nursing care of patients. This is not a new concern, or a concern of a few, but rather of nurses generally. We can no longer fail to prepare and use nurses honestly. Nursing's destiny is indeed the concern of nurses ( Kaiser, 1983, p. 4).

Elizabeth H. Mahaffey, RN, PhD

E-mail: ehmahaffey@hindscc.edu

© 2002 Online Journal of Issues in Nursing
Article published May 31, 2002

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key words: associate degree nursing

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The Relevance of Associate Degree Nursing Education: Past, Present, Future

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Associate degree nursing education remains a relevant choice for students entering the nursing profession. Since its introduction fifty years ago, associate degree nursing education has had a significant impact on the registered nursing population in the United States.

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Demographical Diversity Information about Nursing 

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Demographical Diversity Information about Nursing 

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The number of minority students enrolled in advanced nursing education is increasing. Some 30 percent of students at the baccalaureate, master's, doctoral, and doctor of nursing practice program levels represent minority populations. The number of men in nursing is also increasing. In 2018, 14 percent of pre-licensure RN program graduates were male.

This graph is a part of the Campaign for Action Dashboard, a series of charts and graphs that show goals by which the Campaign evaluates its efforts to implement recommendations in the Institute of Medicine's The Future of Nursing, Leading Change, Advancing Health.

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The Campaign for Action is working to increase the diversity in nursing. We believe that the workforce should reflect the nation's great cultural diversity.

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Scholarly Article: “RN Means Real Nurse”: Perceptions of Being a “Real” Nurse in a Post-LPN–BN Bridging Program

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Scholarly Article: “RN Means Real Nurse”: Perceptions of Being a “Real” Nurse in a Post-LPN–BN Bridging Program

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Janzen et al. - 2013 - “RN Means Real Nurse” Perceptions of Being a “Rea

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New Data Show Enrollment Declines in Schools of Nursing, Raising Concerns About the Nation’s Nursing Workforce - AACN

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New Data Show Enrollment Declines in Schools of Nursing, Raising Concerns About the Nation’s Nursing Workforce - AACN

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Rep’s ‘Elitist’ Slam of Community College Nurses Inspires Criticism, Semi-Apology

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Rep’s ‘Elitist’ Slam of Community College Nurses Inspires Criticism, Semi-Apology

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Rep’s ‘Elitist’ Slam of Community College Nurses Inspires Criticism, Semi-Apology – InsideSources

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A day after an NHJournal report on her demeaning comment about community college education and associate degree nurses, NH Democrat Rep. Linda Tanner is

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Scholarly Article: Our Own Worst Enemies The Nurse Bullying Epidemic

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Scholarly Article: Our Own Worst Enemies The Nurse Bullying Epidemic

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Scholarly Article: LESSONS LEARNED: ANSWERING THE CALL TO INCREASE THE BSN WORKFORCE

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Scholarly Article: LESSONS LEARNED: ANSWERING THE CALL TO INCREASE THE BSN WORKFORCE

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NLN- A Vision for Recognition of the Role of Licensed Practical/VocationalNurses in Advancing the Nation’s Health

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NLN- A Vision for Recognition of the Role of Licensed Practical/VocationalNurses in Advancing the Nation’s Health

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*, **, *** Understandting Social Determinants of Health

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*, **, *** Understandting Social Determinants of Health

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Understanding Social Determinants of Health

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Health Health is a dynamic state of complete physical, mental, spiritual, and social well-being and not merely the absence of disease or infirmity.

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Building a Culture of Health and Health Equity through Native American Nurses

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Building a Culture of Health and Health Equity through Native American Nurses

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Building a Culture of Health and Health Equity through Native American Nurses

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Filipino nurses in America: The history vs. the stereotype

# data[].attributes.subject
Filipino nurses in America: The history vs. the stereotype

# data[].attributes.attachment_link.title
Filipino nurses in America: The history vs. the stereotype