Discrimination and Racism in Health Care

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Effective Date: March 26, 1998
Status: New Position Statement
Originated by: Department of Strategic Planning
Adopted by: ANA Board of Directors

Related Past Actions:
1994 - Position Statement on Ethics and Human Rights
1991 - Resolution on Cultural Diversity in Nursing Practice
1972 - Resolution on Affirmative Action Programs


Summary

Discrimination and racism continue to be a part of the fabric and tradition of American society and have adversely affected minority populations, the health care system in general, and the profession of nursing. Discrimination may be based on differences due to age, ability, gender, race, ethnicity, religion, sexual orientation, or any other characteristic by which people differ. The American Nurses Association (ANA) is committed to working toward the eradication of discrimination and racism in the profession of nursing, in the education of nurses, in the practice of nursing, as well as in the organizations in which nurses work. The ANA is further committed to working toward egalitarianism and the promotion of justice in access and delivery of health care to all people.

Background:

Discrimination, as defined in the American Heritage Dictionary (1992), is "Making a difference in treatment or favor on a class or categorical basis while disregarding individual merit; (2) acting on the basis of prejudice; and (3) the denial of equal opportunity (i.e. for education, employment, promotions, loans, housing, and health care)". Discrimination of this nature is not always easy to prove, however its consequences are quite concrete. Prejudice, on the other hand, involves thoughts, attitudes, insensitivity, and ignorance, not actual behaviors or demonstrable denials of opportunity. Prejudice frequently leads to discrimination. A prominent and particularly negative form of prejudice in America is racism. Too often racism is manifested in the attitudes of nurses and other health care providers toward patients and their fellow professionals of different ethnic groups. Ethnicity is distinct but often confused with race, and discrimination occurs along ethnic as well racial lines. Racism has an adverse impact on the health care environment and on those receiving health care services. In the health care arena, differential access to resources limits basic and preventive health care to members of some groups. Unequal distribution of health care resources results in morbidity and mortality rates that vary substantially among racial and ethnic categories and economic classes. Health care, as a resource, must be distributed fairly and equitably. Nurses and other health care providers may be victims as well as perpetrators of racial discrimination. Selective mistreatment often undermines the work experiences of individuals who are identified with groups that are the targets of discriminatory behaviors. ANA believes that nurses and other health care providers have a responsibility for assuring a workplace which recognizes individual differences while being free of discrimination based on racial and ethnic distinctions.

According to the ANA "Code For Nurses" (1985), "the nurse provides services with respect for human dignity and the uniqueness of the client unrestricted by considerations of social or economic status, personal attributes or the nature of health problems". All nurses should strive to create environments that encourage quality health care practices; all patients deserve quality care. Health care that is not sensitive to differences in race, specific health practices and needs of different groups is not quality care and can even be harmful. For instance, failure to provide preventive services, such as lead screening, for inner city children living in poverty, or for sickle cell disease in African American children may have life threatening consequences.

Differences in Health:

Despite some recent improvements in health care delivery, many problems continue for most minority populations. There are persistent and sometimes substantial differences in the health of Americans. Minorities suffer from certain diseases at up to five times the rate of white Americans. For instance, cancer is the leading cause of death for Chinese and Vietnamese. Surveillance, Epidemiologic and End Results (SEER) data from the National Cancer Institute show that Korean stomach cancer rates are five times the rate for the total population. Vietnamese women suffer from cervical cancer at nearly five times the rate of white Americans. The number of Hepatitis B cases among Asian American and Pacific Islander children is two to three times higher than for children in the United States. Compared with the general population, Hispanics have a higher incidence of cancer of the stomach, esophagus, pancreas and cervix. There is a significant problem in the Native American population with diabetes, sudden infant death syndrome and congenital malformations. Despite some improvements in health care for African Americans since the 1960's, African Americans have a life expectancy that is six years shorter than the life expectancy for white Americans. African American men less than 45 years old have a 45% higher rate of lung cancer and ten times the likelihood of dying from hypertension than white men under age 45. Research is needed to better understand the epidemiology of these differences.

Differences in Research Needs:

Efforts to address racial and ethnic disparities in health will require nurses, physicians and other health care providers to develop new approaches, in consultation with experts in minority communities, to ensure that research, treatment, and education programs for diabetes, cancer, tuberculosis, and other diseases which affect minorities disproportionately, are available in local communities and nationwide.

Every year hundreds of clinical trials for new drugs are conducted at medical centers throughout the country. Medical advances would not occur without clinical trials which help to determine if drugs work for a specific purpose. In addition participants have the opportunity to work with specialists who have the latest information on their disease. However, historically, minorities have been grossly under-represented in clinical trials conducted by federally funded institutions such as the National Institutes of Health (NIH). A major impediment for minority participation is a lack of trust in the medical establishment based on past experiments such as the Tuskegee Syphilis Study and the South Dakota Hepatitis-A Vaccine Study on American-Indian babies.

The Tuskegee Syphilis Study was conducted by the U.S. Public Health Service from 1932 to 1972. This study intentionally withheld treatment from 399 poor African American men suffering from syphilis. The goal was to observe the long-term effects of syphilis. The participants were never made aware of or given treatment even though penicillin became widely available in the 1940s and later became a standard treatment for syphilis. Over three fourths of the subjects died from complications of syphilis. Many of those who survived became blind and crippled. The experiment was conducted without the benefit of the patients' informed consent.

In the South Dakota experiment, newborn Lakota Sioux Indians were injected with either an experimental hepatitis type-A vaccine or, as a control, with an approved hepatitis type-B vaccine. Indian babies were selected because many reservations, being poor, rural and crowded, experienced epidemics of hepatitis-A every five to seven years. An epidemic in 1990 and 1991 infected more than 500 people and resulted in numerous hospitalizations and one death. The goal of the program was to inject approximately 105 babies and, after studying the results, offer the vaccine to everyone. The Indian Health Service officials, who assumed responsibility for the trials, stated that Indians as a group stood to benefit from hepatitis-A vaccine. However, in a letter to doctors, the health service warned of anaphylactic reactions and such possible side effects as cancer, jaundice and death. Lawsuits filed by Indian families said the parents were not told of such potential risks when their permission to vaccinate was sought. They believed the experiments were racist and deceptive. This case highlights the animosity and intense suspicion with which many Indians still regard the Federal government.

ANA believes health care providers are professionally, morally and ethically obligated to explain the purpose, risks, potential side effects and benefits of each study before a patient agrees to participate. An informed consent document that includes all relevant information, in language the patient understands, should be thoroughly discussed with the patient, the patient's family and/or significant other. Safeguards must be put in place to ensure that prospective participants are given complete information on the nature of all research studies.

Other barriers to minority participation in clinical trials deal with culture and language. Often minorities feel more comfortable with minority health care providers and researchers who have an understanding or appreciation of their culture.

Differences in Representation in the Health Profession:

The March 1996 Sample Survey of Registered Nurses by the U.S. Department of Health and Human Services reveals that the profession of nursing continues to be 90% white female. As American society is evolving into one of increasing diversity, this lack of diversity in the nursing workforce is potentially harmful to the profession and the population it serves. ANA believes greater and better use of the diverse human resources of our country is a national imperative. The under-representation of minorities in the health professions is but one indicator that we have failed to recognize and develop fully the human resources of our diverse population. Our ability to maintain a position of global leadership depends on our willingness to recognize, stimulate, and develop capacities of all segments of society and to acknowledge the needs of those segments currently under represented in health careers. ANA is concerned about future productivity across most U.S. industries, including health, unless we can adopt policies that support the development of all individuals within our diverse ethnic and racial populations.

Differences in Access and Prescribed Treatments:

Underlying some of the racial disparities in the health among Americans are differences in both need and access: minorities are more likely to need health care but are less likely to receive health care services. For example, recent studies have shown that even when minorities gain access to the health care system and even when there is a comparable ability to pay for services, they are less likely than whites to receive surgical or other therapies. ANA believes that disparities in health care based on personal characteristics such as race must be avoided. Whether such disparities are caused by differences in income and education, socio-cultural factors, or inequitable treatment decisions by the medical and nursing professions, they are unjustifiable and must be eliminated. Nurses, physicians, and other health care providers should examine their own attitudes and practices to ensure that prejudice based on race and ethnicity does not affect their clinical judgements in health care.

Previous ANA Action: ANA abhors the recent rise in racist and discriminatory behavior in this country including hate crimes, church burnings and the resurgence of groups advocating white supremacy. ANA believes that action is necessary to halt this trend. The ANA position statement on "Ethics and Human Rights" (1994) is based on the following beliefs:

  • Human beings deserve respect as ends in themselves, and therefore, deserve health care services that are equitable in terms of accessibility, availability, affordability and quality;
  • Justice requires that the differences among persons and groups are to be valued. When those differences contribute to the unequal distribution of the quality and quantity of health care, then remedial actions are obligated;
  • Because nursing care is an essential but sometimes limited commodity, allocation of care is a pressing issue that cannot be effectively addressed when specific individuals are excluded or when the burdens of limited access are borne by particular groups;
  • The principle of justice applies to nurses as providers as well as to nurses as recipients of care. ANA is committed to addressing the need for racial and ethnic diversity among nurses. Such diversity is a critical element in providing fair and equitable care.

It is therefore timely for ANA to assume a greater leadership role in developing both internal and external policies and programs to end discrimination and racism in the profession and in society.

Conclusion:

The United States has been undergoing racial change throughout its history but never at the pace and manner occurring now. Within the next fifty years, whites as a share of the total population will decline from 75% to under 50%. In many localities so called minorities are now, in fact, the majority. The African-American population will increase in size but remain at about 12% of the total. Depending upon immigration trends, intermarriage and racial self-identity, the Hispanic population may increase to more than one-quarter of the total while Asians may increase from their present 4% to 8%. Given these trends, ANA believes it is critically important for Americans to come to a shared understanding of the negative consequences of discrimination and racism which still pervades our society and be willing to take individual as well as collective actions to bring America closer to our ideal of equality and justice.

Equality and justice must also extend to other minorities such as the aged and disabled. Health care that is individualized to the health practices and specific needs of each person and/or population group is vital to maintain and improve the health of all Americans. Nurses must work to include diversity within the health professions, processes of health care delivery, and desired patient outcomes in order to deliver the holistic care we profess is our primary goal.

Therefore, ANA will develop a strategic plan which addresses the eradication of discrimination and racism in and by the nursing profession. This plan must be implemented, adequately funded and evaluated after three years and revised as necessary.

ANA Policies

Internal

The American Nurses Association will:

  1. Reaffirm the principles in the ANA Code of Ethics (1985), the ANA Position Statement on Ethics and Human Rights (1994)and the International Council of Nurses' (ICN) statement on "The Nurses Role in Safeguarding Human Rights"(1983).
  2. Encourage and promote cultural diversity and linguistic training/education for nurses at the national and state levels of the association that includes both awareness and skill building components.
  3. Reaffirm our commitment to employ nurses from culturally and otherwise diverse backgrounds into the association at the national level and encourage parallel policy and action at the state, district and local unit levels.
  4. Encourage states to prepare and promote nurses from culturally and otherwise diverse backgrounds into leadership positions within the association.
  5. Reaffirm our commitment to include nurses from culturally and otherwise diverse backgrounds on boards, congresses, committees, task forces, and other policy-making bodies at the national level and encourage parallel policy and action at the state level.
  6. Foster the development of strategies to counter racism in the profession of nursing. Serve as a clearinghouse for information on this topic and distribute all relevant materials to state nurses associations and other professional nursing organizations.

External

The American Nurses Association will:

  1. Foster development and implementation of comprehensive multilingual and multi-cultural nursing care delivery models to address the specific health needs of culturally and otherwise diverse populations.
  2. Foster development and implementation of changes in curricula in undergraduate nursing programs to include multilingual requirements, transcultural theory, and affective and cognitive learning experiences to meet the health care needs of culturally and otherwise diverse populations leading to transcultural competence in practice.
  3. Stimulate the development and implementation of graduate nursing educational programs and research on nursing interventions and patient outcomes for health problems specific to minority populations.
  4. Encourage recruitment and retention of people from culturally and otherwise diverse backgrounds as faculty and students in schools of nursing.
  5. Encourage and promote programs in continuing education at the national level which will assist registered nurses in their efforts to work collegially with co-workers of diverse population groups to provide safe, sensitive, effective nursing care for culturally and otherwise diverse people.
  6. Focus on multiple aspects of professional development that affect participation of under-represented minorities in the health professions, such as education, academic achievement, and mentoring.
  7. Support passage and enactment of public policy at the national and state levels which strives to eliminate broader problems such as unemployment, illiteracy, and poverty which tend to affect minority populations disproportionately.
  8. Support the election and appointment of public officials from diverse racial and other minority populations whose views are consistent with the mission and values of ANA.
  9. Support the development of model social and public health programs that emphasize empowerment of the community and stress economic independence for minority populations.
  10. Support the passage and enforcement of laws and regulations that provide sanctions against racial and ethnic discrimination.

References

  • American Medical Association Council on Ethical and Judicial Affairs. (1996- 1997). Black-White Disparities in Health Care. In Code of Medical Ethics: Current Opinions and Annotations (pp.91-95 ). Chicago, Illinois.
  • American Nurses Association. (1994). Position Statement on Ethics and Human Rights, Kansas City, Missouri.
  • American Nurses Association. (1985). Code for Nurses With Interpretive Statements (p. 2). Kansas City, Missouri.
  • Jacqueline A. Dienemann (Ed.). (1997). Cultural Diversity in Nursing - Issues, Strategies and Outcomes, Washington, DC. American Academy of Nursing.
  • Farley, Reynolds. (1997). Presentation to President Clinton's Initiative on Race Unpublished Paper. Washington, DC.
  • Institute of Medicine. (1994). Balancing the Scales of Opportunity-Ensuring Racial and Ethnic Diversity in the Health Professions, Washington, DC. National Academy Press.
  • Lee, Philip R. and Carroll Estes (Eds.). (1997). The Nation's Health. 5th ed; Massachusetts: Jones and Bartlett.
  • National Association of Social Workers. (1996). Racism. Social Work Speaks Washington, DC.
  • Baum, Dan (1992). Vaccine Test Racist, some Indians Says. Chicago Tribune, Chicago, IL.
  • Brooks, Jennifer (December 1997/January 1998). Minority Participation in Clinical Trials. Closing the Gap. (p. 3). Washington, DC.
  • Brooks, Jennifer (December 1997/January 1998). Career Clinical Trials: Barriers to African American Participation. Closing the Gap. (p. 7). Washington, DC.
  • Ohio Nurses Association. (1997). A Statement on Nursing Workplace Being Free of Racism. Columbus, Ohio.
  • Washington State Nurses Association. (1996). Affirmative Action For Culturally Diverse People. Seattle, Washington.
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