Pushing Back on the System of Fear

By Stephen Nelson

Since the New Year and my writing about my fears of people of color, I’ve been thinking a lot about this. As I re-read my blog post about my upbringing and the instillation of fear of people of color, especially black people, it strikes me as somewhat hopeless. Especially the part where I say:

“This fear is ingrained. It is automated. It is immediate. It is engaged even if we are not conscious of it. We don’t have to do anything to make it happen. It just does. Just like my car doors locking; my stereotyping, bias, and fears play out automatically. Sometimes I’m aware of this, and sometimes I’m not.”

This feels like maybe we can’t do anything about it. This is absolutely not the case. This is not the case because the patterns I’ve identified within myself are the product of intensive socialization on the part of a White-dominant system. This system miseducated me by creating false narratives about people of color through mainstream media and by segregating me from people of color to decrease the chances that these narratives would be disproven through my own relationships with people of color. This is not just “happenstance”, but rather a calculated and intentional move on the part of the White dominant structure in order to make sure that White people go along with the system and keep it in place. So, my fear only SEEMS ingrained because it is meant to feel that way. Thus it will also feel unchangeable in the minds of Whites.

This past November I was presenting at the Overcoming Racism Conference in St. Paul. We had a lively group in our workshop with approximately 20 participants. I presented on the social determinants of health as well as institutionalized racism and how it affects health care delivery. I focused quite a bit on stereotyping and unconscious biases of all of us, specifically health care providers. Here is one of the slides I showed during that presentation:

After the workshop was completed and I was leaving the building to trudge through the snowy cold streets of St. Paul to get to my car, one of the participants of my workshop flagged me down. She was a person of color. We talked for quite a long time and she was very complimentary about the workshop. She did give me one piece of advice. She suggested that I change but one-word in the entire presentation. As I pondered her recommendation, and I continue to do so, she is absolutely right. Since then, I have changed the above slide. This is how the slide reads now when I present on the topic of health care provider bias. See if you can see the subtle but so important and impactful change.

A single word can have such profound meaning. One single word. Saying that unconscious biases are normal lets White people off the hook in a sense. White people cannot help it. It is just the way it is. There is nothing Whites can do about it. My use of the word normal essentializes unconscious racial biases.

One single word. Using the word common helps to illustrate the frequency with which White health care providers rely on stereotyping during work with patients and families. I do feel that it is important to stress the important role of health care provider bias in the persistence of racial health inequity. Using the word common does this without essentializing biases for the listener and for myself.

I am so very thankful for the advice I received. One simple word.

My fear and biases are not normal. These are not an essential part of my being. They are not permanently ingrained. As I stated in January: “So, if I am honest with you I will say that I still have some fear of black people.” But what might be more accurate would have been to say, ‘if I am honest with myself, I am still plagued by the socialized fear of black people I was given throughout my youth and into early adulthood’ because this is really what I am struggling with in my daily interactions with patients, friends, family and everyday folks I encounter throughout my day. I did not ask for the messages I received, no White person ever does. And they have taken root and it is a slow and arduous process of noticing the fear, confusion and misunderstanding they produce in me on a regular basis.

And, I work daily to undo this and push against this fear and unconscious bias. Before entering the room to see a patient, I take just a few seconds to check my bias and potential discomfort if the patient is a different race than my own. I focus on our shared humanity. I can find something in common with a person of color as easily as I can with a white upper middle-class suburban family. I find that I spend just as much time with families of color as I do with white families. This helps to break down some of the fear and mistrust of the healthcare system that affects so many patients of color. It has also translated into my offering specific therapies to all appropriate patients without my preconceived notions of their ability to adhere to our treatment plans.

But, I also know that this kind of individual “self-check”, while important, is not enough. For this reason I also try to see how the system of racial oppression is situated at work and do my best to challenge those structures and the ways they deny resources, in some cases life-sustaining resources, to families of color. Working on my own unconscious bias and stereotyping is critical, but I must also work to dismantle racism at the institutional level.

I want to share a specific example of how working on our unconscious biases improves patient trust and outcomes. My hospital has been part of a multicenter NIH study of sickle cell disease, a disease that in North America predominantly affects people of African descent. Participation in clinical trials by people of color has historically been very low. There are many reasons for this that include mistrust on the part of the patient as well as bias on the part of the provider. Because of fear and unconscious bias patients of color are often not approached (by the majority white providers) to participate in clinical trials. Unfortunately, this translates into most evidence-based protocols being developed using outcomes of white patients. This only perpetuates healthcare disparities for people of color.

I am proud to say that the sickle cell trial met its accrual goals one year ahead of schedule. Compliance with the study requirements was greater than 98%. The study was completed ahead of schedule. All of the 121 participants on this trial are of African descent. This was one of the most successful in NIH- sponsored clinical trials in history, and not a single patient was White.

We can improve care for patients of color. We can undo our fear and unconscious bias. We have to push back against the systems of fear that are in place. We can do this.