I attended a workshop on developing equitable health information materials, emphasizing that people are more responsive to data when individuals of similar complexion and/or features are represented. This concept originated in education, where research indicated that youth learned better from teachers with similar characteristics, and it was subsequently extended to health care. However, universal application is unrealistic, as Black children will not always have Black teachers, and patients of color cannot be guaranteed corresponding treatment staff.
Within seconds, a criticism emerged that the brochure under examination lacked representation of non-cisgender people. How the viewer discerned this, I have no idea; was the individual implying that one can determine a person’s gender by sight? This made me consider what would be required in health care if the commenter’s belief, which is also advocated by others as promoting equity, were carried to its (il)logical conclusion.
In a 2023 paper authored by two biologists, echoing many other biologists, it was emphasized that the public and even fellow academics, in an effort at political correctness, wrongly conflated biological sex and gender, and that studies performed with this belief were bad science. These authors reinforced that sex is biological and, except for rare instances, limited to two possibilities, while gender is a potentially unlimited social construct.
A few weeks earlier, I attended a presentation that explored gender variations. It was noted that no standardized classification exists, as different professional organizations recognize divergent variants. Nonetheless, assuming the speaker’s veracity, there are presently 72 distinct genders, a number accepted by at least one professional organization.
Another issue currently questioned is race/ethnicity, with some scientists and activists arguing that these designations no longer have meaning and are, in themselves, discriminatory. Other researchers and organizations contend that these categories retain continued and necessary salience in understanding various biological and sociological data, and many government agencies have shown no inclination to eliminate their use.
Returning to the complainant’s contention, if we were to require a corresponding physician by ethnicity, gender preference, and biological sex for each potential patient variant, we would need 864 practitioners in every specialty on a hospital’s staff—an absurd and unworkable concept!
Considering health care equity as color-matching or a similar construct is misguided. Rather, we should ensure that diverse, qualified individuals have equal opportunity to enter health care professions and that all patients have access to equal, quality, and courteous care. These goals are more appropriate and more aligned with Martin Luther King Jr.’s beliefs.
The current lack of equity is a significant problem that results in poor health outcomes for many people, not only those of color but also women regardless of color, disabled people, and others, and it deserves redress. Discrimination is millennia old, and even assuming it is resolvable, it will not be remedied without many years of effort. To think otherwise is naïve. It is not uniquely American but a global propensity that can be demonstrated on every continent and in every culture.
Two broad types of inequitable practices exist: structural and personal. The former is an outgrowth of the latter, as laws and regulations arise from and are perpetuated by people. The Commonwealth Fund’s 2024 Health Disparities Report examined personal biases but recommended systemic remediation strategies. The suggestions were simplistic and implied that laws and regulations could easily be modified to eliminate both forms of bias, forgetting (or ignoring) that these strictures are political creations—the product of continuous tension and compromise between different political philosophies. Depending on which philosophy is ascendant at any given point, these strictures expand or contract.
On the individual level, interventions like cultural sensitivity training are popular and have been attempted in health care, though with little positive effect. This is unsurprising, as they lack a scientific base and have targeted only those who have patient contact, most of whom have matured in environments saturated with prejudicial messages. Post-secondary and professional education does little to ameliorate these beliefs, nor does clinical training, as evidence has shown that senior residents, fellows, and attendings often reinforce biases.
Can we realistically expect that single-session programs, averaging 5 1/2 hours, can counterbalance years of immersion in biased environments? What is needed, idealistically, is a transformation of the greater milieu in which health care is embedded. However, scientists have found no effective means of evoking change of this magnitude short of conquest or cataclysm. Nonetheless, medical schools and medical centers are sufficiently insular to culture unto themselves and can induce change by creating an environment emphasizing equity as a social and medical “good,” supported and lived by administrators as an exemplar for staff to follow. It has been found that absent active administrative participation, any attempt at modification will fail.
This approach was used with safety and sanitary practices, accompanied by posters, an inaugural party, classes, T-shirts, and more, and it was found to be (at least partially) effective. A few small-scale experimental health care equity programs of this type have been attempted and have yielded promising results. However, they are days-long, may require yearly repetition, and may not transfer to large institutions. Thus, despite present remonstrances and urgency, there are neither easy nor rapid answers. This lack, however, does not mean that we should not continue our efforts for change.
M. Bennet Broner is a medical ethicist.
