With the publication of “Eradicating Racism in Endocrinology: An Endocrine Society Policy Perspective” in the January issue of The Journal of Clinical Endocrinology & Metabolism, the Endocrine Society formally calls for policies to address racial and ethnic inequities in the endocrine workforce and in access to care.
James Baldwin began his 1956 essay “Faulkner and Desegregation” with, “Any real change implies the breakup of the world as one had always known it, the loss of all that gave one an identity, the end of safety.” Baldwin was expressing his disappointment that William Faulkner had famously told the NAACP to “go slow” when it came to desegregation in the South. Baldwin goes on to conclude: “There is never time in the future in which we will work out our salvation. The challenge is in the moment, the time is always now.”
Six decades later and the medical community is still in need of a breakup of its own world. Racial and ethnic disparities have spread their tentacles throughout all aspects of healthcare, whether some people want to pretend not to feel them. During the ENDO 2021 session, “Addressing the Impact of Structural Racism on Endocrinology and Health Care,” Sherri-Ann Burnett-Bowie, MD, MPH, discussed just how deeply rooted structural racism is in our healthcare system. Burnett-Bowie works as a clinical investigator in Massachusetts General Hospital Endocrine Unit in Boston, and she told attendees that their policy is to review clinical practices to determine how – not if – racism is affecting clinical decisions.
In January, the Endocrine Society published a policy perspective in The Journal of Clinical Endocrinology & Metabolism that aims to address all facets of racial and ethnic inequities in the healthcare system, from bench to bedside. The authors write: “Here we 1) convey a message to the broader membership on a policy priority: eliminating racism in endocrinology; 2) discuss the impact of racism in endocrinology by reviewing sources of disparities and sharing anticipated consequences of racism in clinical and research settings; and 3) propose interventions (changes in education, practices, and policies) aimed at eliminating racism in endocrinology.”
“Health disparities are one of the most pressing issues facing science and medicine,” says Ruban Dhaliwal, MD, MPH, research physician at Massachusetts General Hospital, member of the Endocrine Society’s Advocacy and Public Outreach Core Committee, and chair of this policy initiative. “As endocrinologists, we have a responsibility to take actions to eliminate racism in our discipline and for our patients. The Endocrine Society has incorporated its commitment to diversity, equity and inclusion into all facets of its education and advocacy initiatives and programming.”
Dhaliwal first brough this perspective idea to the Endocrine Society’s Committee on Diversity and Inclusion (CoDI) in the summer of 2020 – when the Black Lives Matter movement was gaining more supporters after the murder of George Floyd, coupled with the fact that the COVID-19 pandemic was uncovering even deeper layers of health disparities.
“I am excited about this perspective, which has been more than a year in the making,” says Rodneikka Scott, chief membership and diversity programs officer at the Endocrine Society. “In it, we honor our mission, recognizing that eradicating racism is inextricably linked to achieving our mission to unite, lead, and grow the endocrine community to accelerate scientific breakthroughs and improve health worldwide.”
“I want to thank the many members of our community who represent research and clinical care, who gave their time, insights, and passion for developing this perspective,” she continues. “Our success will depend on the ongoing efforts of an entire endocrine community committed to eliminating racial and ethnic disparities.”
Make no mistake: addressing these issues and promoting diversity, inclusion, and equity across healthcare is a top priority for the Society, and the purpose of this paper was not to point out gaps in the Society’s health equity work, but to acknowledge that there’s still much work to be done. In fact, the Society has been leading these efforts for almost 30 years. But again, the time is always now.
A Public Health Threat
The introduction of the Society’s perspective states bluntly, and accurately, that racism is destructive to individuals and society, and is a direct threat to public health. It’s no secret that racial and ethnic minority populations have the highest prevalence of diabetes in the U.S., while at the same time being denied routine care and experience worse complications from diabetes. And while Black Americans are far more likely to be diagnosed with diabetes and are far less likely to have their condition managed because of prohibitive costs, this population is at the most pronounced disadvantage when it comes to access to insulin, non-insulin diabetes medications, and diabetes technology including continuous glucose monitoring and insulin pumps. Lack of access to these highly beneficial medications and tools is due not only to high costs, but also due to provider implicit or explicit bias.
Osteoporosis is screened less often in African Americans, although after a fracture, that population is more likely to have longer hospital stays, and a significantly higher risk of disability, death, and destitution than White Americans.
In Mississippi, where Licy L. Yanes Cardozo, MD, works as associate professor in the Department of Cell and Molecular Biology at University of Mississippi Medical Center in Jackson, Black people are twice as likely to die from diabetes. (A November 2021 report from the Commonwealth Fund found racial health disparities across all 50 states, but Mississippi ranked among the worst.)
But it’s precisely where Cardozo feels she needs to be, and why she says she feels honored to help co-author the Society perspective. “As a practicing endocrinologist in Mississippi, a state with a large population of minorities, to be part of this manuscript is both a privilege and a personal necessity,” she says. “We can be the voice of those who do not have one; the time for a change is now.”
The authors of the perspective further point out that it’s extremely important that when measuring disparities, to test for disparities within racial and ethnic subgroups and to not assume that racial and ethnic minority groups are homogenous.
“The systems and pathways that we research and treat are complex, and the challenges many of our patients face our enormous. The impact of racism (internalized, interpersonal, institutional, and structural) is complex, and eradicating racism will require the same ingenuity and innovation that we use to research and treat the complex disorders that make up the field of endocrinology.” – Joshua Joseph, MD, associate professor of Endocrinology, Diabetes, and Metabolism, The Ohio State University College of Medicine, Columbus, Ohio
According to Rocio Pereira, MD, chief of Endocrinology at the safety-net hospital system Denver Health, associate professor of medicine at the University of Colorado, and co-author of the Society perspective, prevalence of chronic diseases can be very different among Asian Americans from China, compared to those from the Philippines, in Latin Americans from Mexico compared to Latin Americans from Peru or other parts of South America, or Black/African Americans from the Caribbean compared to Black/African Americans from the United States. “This variability likely reflects differences in social determinants of health that impact each population. We must continue to look for these differences and to identify and address the factors, including racism, that lead to these disparities,” she says.
“Minority Tax” Rebate
The plan had been to publish the Society perspective sooner, but as the authors saw just how deep the problem was, they wanted to dive into the scientific literature in to see exactly how race plays a role in endocrinology. For instance, the authors write about the ongoing debate on whether to include race adjustments in clinical algorithms. The Endocrine Society will re-examine those same questions in the coming year.
Joshua Joseph, MD, associate professor of Endocrinology, Diabetes, and Metabolism at The Ohio State University College of Medicine in Columbus, and co-author of the Society perspective, points to The American Society of Nephrology’s recent re-evaluation of the use of race in the eGFR equation, and their published findings that the new equations that do not include race are more accurate. “It is important to examine the use of race in clinical algorithms through evaluating the science and encouraging research to fill the gaps to inform the best treatment and care of individuals with endocrine disorders to ensure that no harm is done via race-based algorithms,” he says.
Then there’s the minority tax – racial and ethnic minorities are often uncompensated for additional duties, often denied raises or promotions even after an increased workload. Pereira tells Endocrine News that this minority tax is an added burden minority individuals face due to underrepresentation in the health system. She explains that minority providers have this expectation and self-perceived responsibility to serve minority populations, focus research on health disparities, participate in organizational equity work, mentor minority trainees, educate non-minorities about health equity and racism, and serve as minority representatives in committees, workgroups, and so on.
“This work is most often un- or undercompensated and leaves less time for work that more directly leads to promotions, salary increases, and recognition by our peers,” Pereira says. “The solutions to the minority tax are to increase minority representation in the health workforce, and to appropriately acknowledge and compensate minority individuals for this added work. It is also necessary for non-minorities to join in the work of eliminating racism and health disparities.”
“The responsibility for training and education should not be uncompensated work falling on the shoulders of racial/ethnic and other minoritized faculty,” Joseph says. “These challenges are all of our challenges, and it is the work of all us to advance equity. This journey will require open hearts and minds.”
Updating Antiracism Curriculum
Opening those hearts and minds will take some work. There might still be some out there who feel comfortable being “non-racist” or even “colorblind,” but those frames of mind simply won’t cut it anymore, not if there’s to be real change. This is a country that has actively denied resources and opportunities to minorities (see redlining, for instance), and continues to do so.
“Claiming to be ‘non-racist’ implies that we as members of our society do not participate in any discriminatory practices that are still in place and play no role in perpetuating the situation,” Pereira says. “Practicing anti-racism means looking for those discriminatory practices and dismantling them, identifying our own implicit biases, and not acting on them, being ‘upstanders’ and not just standing by when we witness an injustice or an act of racism. In order to become a more just society, we must all practice anti-racism.”
“Health disparities are one of the most pressing issues facing science and medicine. As endocrinologists, we have a responsibility to take actions to eliminate racism in our discipline and for our patients. The Endocrine Society has incorporated its commitment to diversity, equity and inclusion into all facets of its education and advocacy initiatives and programming.” – Ruban Dhaliwal, MD, MPH, research physician, Massachusetts General Hospital, Boston, Massachusetts
Education will be crucial to preventing racism and bias from creeping into the healthcare system. “To avoid frameworks of colorblindness and empower future generations, structural competency must be included in the antiracism curriculum,” the Society perspective authors write. “Trainees need to be taught about redlining and discriminatory practices that have made racial/ethnic minority populations more vulnerable to lower socioeconomic conditions, poor quality of life, inadequate educational opportunity, interchanges with the criminal justice system, and substandard healthcare.”
Workplaces should strive to be more equitable by using antiracist policies and practices. The endocrinology leadership, endocrinology providers, clinical research coordinators, the research workforce, and clinical trial participants should reflect the populations served. The authors of the Society’s perspective write that healthcare organizations and institutions should measure and track not only racial/ethnic minority diversity but also measures of retention, promotion, and compensation specific to adult and pediatric endocrinology to reach the goal of an equitable workplace.
“Evaluating and addressing the effects of racism across the translational research spectrum, developing interventions for antiracism in the conduct of research, and increasing diversity in the research workforce and in clinical trial participation are all key to addressing racism in research,” the authors go on to write.
“Training regarding implicit bias, cultural and structural competencies, microaggressions, mistreatment, and racism in healthcare and science are vital for educating healthcare professionals and scientists to advance the treatment and care of patients with endocrine disorders,” Joseph says. “The gains in training will be enhanced by policies to ensure implicit biases do not hinder care and harm patients.”
An Ethically Different Path Forward
The authors of the JCEM article, “Eradicating Racism: An Endocrine Society Policy Perspective,” conclude that the healthcare system must go beyond declarations and plan an ethically and structurally different path to a new future and move forward to eradicate racism in healthcare. “Our cohesive efforts need to be conscious, deliberate, and additive to disrupt the reductive nature of race/ethnic labels and to create an avenue for equitable health for all individuals,” they write.
“[The perspective] acknowledges that although eradicating racism is a tall hill to climb, we all have a part to play in identifying and remedying inequity in education, research, and care,” Scott says. “The piece reveals relevant opportunities for the endocrine community to elevate equity by recognizing and engaging different communities and leading inclusively.”
Pereira says that the Society should continue to focus on two areas: increasing diversity and increasing awareness. “Increasing the diversity of the workforce, and particularly minority representation among health system leaders, will expand our ability to see people as individuals and improve the care we provide to peoples of color,” she says.
Pereira points to the Society’s FLARE and EXCEL programs in its efforts to diversify the endocrinology workforce, as those programs support the career development of underrepresented minority endocrinology researcher trainees and provide leadership training to clinical endocrinology trainees and early-career clinicians, respectively.
“Increasing awareness of systemic racism and its impact on the health of our communities will compel more of us to join efforts to identify and eradicate racist practices and policies,” Pereira says. “Increasing the awareness of our own implicit biases can help us question our own actions and maybe stop ourselves from acting on those biases.”
“To fix racism we need a strong and sincere commitment from all members of the Society. Racism is a problem for and from all of us. Education and resources are key in generating the changes that will benefit all of us. Eliminating racism in medicine will not only improve health outcomes but will also improve the quality of life of all of us.” – Licy L. Yanes Cardozo, MD, associate professor, Department of Cell and Molecular Biology, University of Mississippi Medical Center, Jackson, Mississippi
In Columbus, Joseph, colleagues at The Ohio State University, and the African American Male Wellness Agency led a clinical trial focused on improving Life’s Simple 7 (glucose, cholesterol, blood pressure, body mass index, physical activity, diet, and smoking) among Black men that Joseph says the participants affectionately called Black Impact. The six-month study incorporated health education, physical activity, and referrals to address social needs and led to significant reductions in body weight, body mass index, cholesterol, glucose, and an overall improvement in healthy diet and cardiometabolic health.
“The key to the program was not only understanding the subpopulation through research and community engagement but inviting the subpopulation to the table as equal partners to co-develop and co-design the intervention in a process that included bi-directional trust-building,” Joseph says.
Data Don’t Lie
Endocrinologists are especially well-positioned to address these issues and confront these problems. After all, endocrinologists typically choose that specialty because they like solving complex problems. “The systems and pathways that we research and treat are complex, and the challenges many of our patients face our enormous,” Joseph says. “The impact of racism (internalized, interpersonal, institutional, and structural) is complex, and eradicating racism will require the same ingenuity and innovation that we use to research and treat the complex disorders that make up the field of endocrinology.”
“As endocrinology researchers we work in interdisciplinary teams to better understand complex processes. As endocrinology educators we make complex topics easier to understand and we challenge trainees to go beyond our own achievements. We must use all these skills and work in partnership with others to identify and eliminate the many processes and practices that continue to support unequal treatment of minority individuals, perpetuating health disparities.” – Rocio Pereira, MD, associate professor of medicine, University of Colorado Anschutz Medical Campus, Denver, Colorado
Pereira agrees, as endocrinologists can draw on their wealth of knowledge and experience used to approach and navigate complicated, even labyrinthine, processes. “We have experience thinking about metabolic diseases that have effects throughout the body, endocrine organs that form feedback loops to regulate each other, aggressive endocrine cancers that are difficult to treat,” she says. “As endocrinology researchers we work in interdisciplinary teams to better understand complex processes. As endocrinology educators we make complex topics easier to understand and we challenge trainees to go beyond our own achievements. We must use all these skills and work in partnership with others to identify and eliminate the many processes and practices that continue to support unequal treatment of minority individuals, perpetuating health disparities.”
In Denver, Pereira is the founder and director of a community-based lifestyle intervention program for Spanish-speaking Latinos. This highly successful program, implemented in partnership with the community organization Vuela for Health, has served more than 2,500 participants, supporting them in making healthy lifestyle choices to prevent obesity and diabetes. Pereira also oversees the Endocrinology team at the safety-net hospital system Denver Health and leads Denver Health’s diabetes quality improvement efforts. Her work has taught her that collaboration and engagement are crucial in equity work. “Equally important is the integration of equity work into existing systems and processes to ensure sustainability,” she says. “A perfect example of such integration is the Society’s incorporation of diversity and equity in every Society committee’s charge. This integration will allow equity work to be embedded in all aspects of the Society’s work now and in the future.”
As Scott says, eradicating racism is a tall hill to climb, but with everyone coming together to sincerely and adamantly fight these injustices, maybe a metaphorical gondola can be installed on that tall hill. And sure, there may still be some out there who consider these fringe problems, but the data showing just how detrimental these racial and ethnic disparities are for healthcare are clear. The time is now to step up. The time is always now.
“We have plenty of data that show that social disparities play a fundamental role in poor health outcomes in endocrinology and medicine,” Yanes Cardozo says. “To fix racism we need a strong and sincere commitment from all members of the Society. Racism is a problem for and from all of us. Education and resources are key in generating the changes that will benefit all of us. Eliminating racism in medicine will not only improve health outcomes but will also improve the quality of life of all of us.”
— Bagley is the senior editor of Endocrine News. In the February issue, he wrote about advances in pediatric growth hormone deficiency treatment.