Building an Anti-Racism Framework

“You don’t look like the doctor,” the patient’s husband says. “I bet I wouldn’t catch you running around in the street, would I.”

The resident stops short, but isn’t surprised. As a Black man, he has confronted such comments many times. This particular comment is prompted, in part, by the recent death of Ahmaud Arbery, a 25-year-old Black man pursued and fatally shot by white community members while he was jogging through his South Georgia neighborhood on February 23, 2020. At the time, no arrests were made.

The resident feels powerless. He turns to leave the room, believing that no matter how he responds, any reply might jeopardize his career — and wouldn’t change anything.

Three months following the death of Arbery, George Floyd dies after a Minneapolis police officer kneels on his neck for nine minutes and 29 seconds. This time, more than 30 medical students and residents in the School of Medicine speak up, penning a pair of letters to school leadership demanding change.

“We had been meeting with medical students from underrepresented communities in the field of medicine for some time in order to address the need for equity, diversity and inclusion in medicine,” said Steven Garfin, MD, interim dean, UC San Diego School of Medicine. “But we realized in this situation with our resident, and after receiving the two letters, a more urgent response was necessary to ensure policies and procedures, as well as education and training, were put in place for medical professionals — and patients.”

And so the Anti-Racism Framework for UC San Diego Health Sciences was established, along with multiple work streams tasked with addressing specific issues and demands raised in the letters.

The five main categories of work are organized by Education; Organizational Training and Enrichment; Recruitment, Retention and Representation; Health Care Policies; and Health Disparities. Each group seeks to improve equity, diversity and inclusion efforts where we all learn, work, teach and receive care.

Invitations to join a work group were sent to all faculty, staff, students and residents; nearly 400 individuals expressed their interest in helping.

In Fall 2020, the work groups began meeting regularly to address issues affecting not just residents, nurses and medical professionals, but hospital support staff, such as environmental services and food and nutrition as well.

“First and foremost, we listened, and it was very painful to hear the stories,” said Garfin. “We thought we understood and empathized, but we can’t do this right unless we’re put in the shoes of others. We opened our eyes to what had to be done because we can’t continue to relive centuries of this systemic racism.”

Immediate actions included leadership recruitment and new positions, such as a Chief Administrative Officer for Health Equity, Diversity and Inclusion at UC San Diego Health and an Assistant Vice Chancellor for Health Equity, Diversity and Inclusion for UC San Diego Health Sciences.

New clinical policies were created to protect staff and set expectations for patients on what is acceptable behavior while receiving care. “We needed to be clear that we will not tolerate racist behavior at UC San Diego Health. These policies are critical because they affect everyone,” said Thomas Savides, MD, chief experience officer at UC San Diego Health and chair of the Health Care Policies work group.

“Specifically, we’ve created two policies on anti-racism that would promote an inclusive work environment for our staff and also help mitigate racist encounters with patients.” For team members, the policies provide guidance on how to manage racist events involving patients. Each event will be managed by a team to evaluate the situation, escalate for additional action, review the event and track patterns.

For patients, certain expectations, rights and responsibilities are expressly outlined, explaining that racism exhibited by patients, family members or anyone visiting the health system will not be tolerated. The updated policy will be provided to patients upon admission.

“It’s been a coordinated effort instead of a lot of people working in silos,” said Savides. “It’s gratifying to know that we’re making changes now that will be in place for decades to come.”

Systemic racism has been public health crisis for centuries. Numerous high-profile deaths, often involving police, fueled an explosion of outrage and grief in 2020, which soon spread to not only include disproportionate violence, but also health disparities and the impact of COVID-19 on communities of color.

“Our CEO Patty Maysent sent out a call to action for physicians and nurse leaders: Stand up and contribute to ensure patients have more equitable health outcomes,” said Amy Sitapati, MD, chief medical information officer of Population Health at UC San Diego Health and chair of the Health Disparities work group. “We were tasked with finding a way to become a cohesive unit of change and the most important thing we needed to do first was allow for open and transparent conversations.”

Sitapati’s work group focused initial efforts on listening to staff who were personally affected by health care inequities, experienced racism in the workplace, and who had witnessed inequities in patients they cared for. Collectively, they were moved by how the pandemic dramatically impacted Latinos in San Diego.

“During the surge, half of my inpatients with COVID-19 only spoke Spanish. We also noticed our Spanish-speaking Latinx population were developing severe cases,” said Sitapati. “Our goal as a work group was to be strategic and personal to ensure we were more inclusive to all patients and staff.”

The work consisted of adapting communications for frontline staff — including nonclinical departments such as food and nutrition and environmental services — to be more linguistically inclusive and at an appropriate literacy level. Translations for staff town halls were provided to ensure staff received leadership updates in the language they best understood.

For patients, the team understood the underlying importance that structural barriers and social determinants were impacting patients at risk for severe COVID-19.

“We were able to load in the social deprivation index for every person, based on their census block provided by the California Healthy Places Index (HPI),” said Sitapati. “Just by knowing where a patient lived, we could determine their HPI and prioritize care for patients with the highest risk.”

Not only did this apply in the clinical setting, but it also assisted the work group in determining where to focus COVID-19 vaccination efforts as UC San Diego Health ramped up its mobile vaccine clinic, which delivers vaccines directly to communities in the greatest need.

Since the Anti-Racism Framework was established, Sitapati has noticed a culture shift at UC San Diego Health that she believes is a result of the collective efforts of all involved.

“The timing of these two extremely emergent events — COVID-19 and the social injustice experienced by persons of color — truly highlighted the severity of health disparities among certain communities and really emphasized the critical need for change,” said Garfin. “Which is why it’s so important for those in medicine to understand how racist sentiments and biases affect a person’s overall health. As educators, this training will become the norm as we mentor the next generation of doctors and work with our current doctors actively providing health care.”