Equity in Healthcare: What is equity in healthcare?

What is equity in healthcare?

Differences in health between populations lead to differences in the quality of life and life span. While an individual’s health status is influenced by genetic factors, it is much more impacted by societal responses to an individual’s social characteristics, such as a person’s race, gender, and socio-economic status, among others. These factors are called Social Determinants of Health (SDH).

The US Department of Health and Human Services defines Social Determinants of Health (SDH) as “the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.” There are five SDH areas which have been shown to have particularly significant impacts on an individual’s health: economic stability, neighborhood quality, education access and quality, social and community context, and healthcare access and quality. As of 2022 there are hundreds, if not thousands, of research studies that describe the degree to which an individual’s social characteristics impact each of these SDH areas, which then in turn impacts their health and their lifespan.

Unfortunately, cultural responses to an individual’s characteristics also influence their healthcare. Populations with privilege generally have the best access, receive the highest quality treatment, and frequently benefit from the best outcomes, all of which contribute to a higher quality of life and a longer life span. Conversely, populations with reduced levels of power and resources in society are more likely to suffer from reduced or no access to healthcare, are provided with a substandard quality of treatment, and consequently, often suffer from worse outcomes which in turn lead to a reduced quality of life and life span. To illustrate the impact this has on patients, an estimated 74,000 Black individuals in the United States die from racism’s impact on all SDH areas, which include reductions in the quality of healthcare, every year.¹ This is the equivalent of a fully loaded Boeing 737 airliner full of Black individuals crashing and killing everyone on board every day. These deaths are completely preventable and are caused entirely by external factors generated by social and cultural bias and discrimination.

Why is this important to EMS providers?

Understanding the inequities in EMS treatment is important for several reasons. First, as healthcare providers we all strive to provide excellent care to all patients, and not just to some patients, although evidence indicates this isn’t happening. Second, under-resourced and underserved populations are more likely to use EMS services for their healthcare needs. EMS utilization rates for all types of medical and traumatic emergencies are higher in poor neighborhoods, in predominantly racial minority neighborhoods, and in neighborhoods with higher rates of residents whom are currently non-US citizens, compared to high socioeconomic neighborhoods, neighborhoods that are predominantly white, and neighborhoods with higher rates of individuals who are currently US citizens, respectively.² Next, the quality of EMS medical treatment can have direct morbidity and mortality consequences for an individual, and when taken together over time, for an entire community of individuals has direct impacts on a community’s quality of life and life span. Finally, medical providers are more likely to make biased decisions in dynamic field-based settings where medical decisions are often made under time pressure, where a patient’s condition is clinically ambiguous, and in situations with incomplete information; all conditions which are common in EMS treatment settings.^3,4

Are there disparities in EMS treatment?

Unfortunately, but not surprisingly, the short answer is yes, disparities are happening in EMS treatment. Before we explore these disparities and what to do about them, we must review foundational concepts regarding cause and effect. A patient’s race doesn’t influence the care they receive, but rather it’s racism’s influence (at the system, agency, provider, and even at the patient level) that impacts the quality of treatment the patient receives. Similarly, it’s not the gender of the patient, but it’s sexism’s influence that operationalizes an impact on treatment, and it’s not the size or obesity status of the patient, it’s sizeism or obesity stigma, etc.

Other areas of medicine have been collecting clear and convincing evidence for decades that racial and ethnic minorities are more likely to receive a substandard of healthcare quality regardless of access, clinical need, or preferences. Several researchers, including myself, have found evidence that for individuals that call EMS for the same injury type (long bone fractures, or burns, or blunt trauma, etc.), racial and ethnic minorities (especially Black patients), while often being in higher levels of pain when they call EMS, are much less likely to receive pain medications from EMS providers.^5–7

Additionally, patients who are overweight, including those with obesity and severe obesity, receive a lower quality of hospital-based healthcare and are much more likely to avoid medical treatment due to the discriminatory behavior they are subjected to when they do seek care. Interestingly, when it was investigated if these same unprofessional and unethical behaviors took place in EMS practice, it was found that when men and women with the same injury interact with EMS for treatment, men who are considered obese receive improved care compared to men who are not obese. However, women who are obese received a reduction in the quality of their EMS care when compared to non-obese women.⁸ Said another way, obesity provides an EMS treatment advantage for men, but a disadvantage for women.

 And finally, another individual characteristic that tends to be discriminated against is a patient’s ability to speak English. Patients with limited English proficiency (LEP) of course have direct challenges communicating with EMS providers, but they are also some of the most vulnerable patients we care for as they are also much more likely to be poor, a racial and ethnic minority, are likely unfamiliar with the healthcare system, and are often recent immigrants. Due to these reasons, and likely others, research currently in-progress suggests that patients with LEP in the setting of traumatic injuries are much less likely to receive a pain screening or pain medications from EMS providers when compared to English speaking patients, even when interpreter services are available. More information and research is needed to improve our ability to improve our treatment of the LEP community.

The topics introduced here provide a brief summary of only a few of the sources of discrimination and prejudice in EMS treatment and we are still learning about them through active research and inquiry.

Why is this happening?

We are humans who exist in and are influenced by our own cultural context. Although we are aware that we have sub-conscious preferences and influences, we also know intellectually that racism and other forms of discrimination are abhorrent, and so it can become particularly difficult to examine the ways in which our societally induced biases affect us. As we have noted earlier, clinical situations that require medical providers to perform under high levels of cognitive load have been shown to create environments that are conducive to racial/ethnic treatment disparities through the activation of heuristics and stereotypes, which are known to contain bias. ^3,4,10,11

We may also be operating with incorrect information. For example, some EMS medical providers may believe, incorrectly, that race/ethnicity is a biological construct instead of a social one. While it has been shown conclusively that there are no medically significant biological differences between individuals of different races/ethnicities, there is evidence that some medical providers nevertheless believe race/ethnicity to be a medically relevant factor and may be adjusting their clinical actions accordingly, resulting in biased treatment.⁹

What can you do?

As an EMS provider, you have many opportunities to improve the equity of your treatment and the development of a more equitable emergency healthcare system as a whole.

Self-awareness

The first step is to build your awareness of your beliefs, both conscious and unconscious, that influence your decisions and your view of the world. Although it can feel daunting at first, careful reflection and observation of the feelings and thoughts that we experience can be revealing, and with practice, becomes easier over time. When evaluating situations, people, and ideas, ask yourself why you feel the way you do? Would you feel different if the race/gender/age/size/apparent social status of any of the people involved was different? Many tools have been developed to help us learn about our biases, including the Implicit Association Test (IAT, implicit.harvard.edu/implicit/takeatest.html), which can be helpful starting points.

Engage others

In addition to self-reflection and learning, we all have the opportunity to engage others in conversations about equity, to ask questions, and to learn from each other. As an EMS provider you will often be in positions where you can be an advocate or be an ally to intervene when you see inequitable care being provided, to support your colleagues as they learn about and work towards providing more equitable care, and in destigmatizing the humility and self-reflection needed for reducing disparities. As patient care topics are raised in your agency, ask questions about equable care and how we can be informed about the degree to which we are providing it.

Education

In choosing to be a medical provider you have also chosen to be a life-long learner. Advances are continuously being made in our understanding of medicine, and the same is true in our understanding of how to provide the highest quality of care to all patients. As you have opportunities to attend conferences or read EMS journals, seek out topics that can enhance your understanding of equity in medical care. Many excellent books have been written about the ways in which societal structures and biases have led to the inequities being experienced right now in our country, and how to reduce them. Great sources to further your education on this topic are included below:

• Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, a report by the Institute of Medicine (US) Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care.
• How to Be an Anti-Racist, a book by Ibram X Kendi.

• Class Matters, a book by correspondents of the New York Times.

• The Problem with Race Based Medicine, by Dorothy Roberts, on YouTube.

• Allegories on Race and Racism, by Camara Jones, on YouTube.

References

1. Benjamins MR, Silva A, Saiyed NS, De Maio FG. Comparison of All-Cause Mortality Rates and Inequities between Black and White Populations across the 30 Most Populous US Cities. JAMA Netw Open. 2021;4(1):1-14. doi:10.1001/jamanetworkopen.2020.32086

2. Burgess DJ. Are providers more likely to contribute to healthcare disparities under high levels of cognitive load? How features of the healthcare setting may lead to biases in medical decision making. Med Decis Mak. 2010;30(2):246-257. doi:10.1177/0272989X09341751

3. van Ryn M. Research on the Provider Contribution to Race / Ethnicity Disparities in Medical Care. Med Care. 2002;40(1):I140-I151.

4. Kennel J, Withers E, Parsons N, Woo H. Racial/Ethnic Disparities in Pain Treatment Evidence From Oregon Emergency Medical Services Agencies. Med Care. 2019;57(12):924-929. www.lww-medicalcare.com.

5. Hewes HA, Dai M, Mann NC, Baca T, Taillac P. Prehospital pain management: Disparity by age and race. Prehospital Emerg Care. 2017;3127(October):1-9. doi:10.1080/10903127.2017.1367444

6. Young MF, Hern HG, Alter HJ, Barger J, Vahidnia F. Racial differences in receiving morphine among prehospital patients with blunt trauma. J Emerg Med. 2013;45(1):46-52. doi:10.1016/j.jemermed.2012.07.088

7. Kennel J, Woo H, Garcia-Alexander G. Treatment and Outcome Disparities for Patients with Obesity in Emergency Medical Services. In: Garcia-Alexander G, Poston, Jr. DL, eds. International Handbook of the Demography of Obesity. Springer; 2022:239-254.

8. Smedley B, Stith AY, Nelson AR (Eds). Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care.; 2003. doi:10.17226/10260

9. Hoffman KM, Trawalter S, Axt JR, Oliver MN. Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proc Natl Acad Sci. 2016;113(16):201516047. doi:10.1073/pnas.1516047113