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Advocating for a shift from race-based to race-conscious medicine

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“I am Italian-Chilean-American (Mapuche), Marie is Haitian-American, and Jenny is Taiwanese-American. We have all experienced racially-tailored care at some point in our lives. Our lived experience enhances the authority of our work,” says Yale School of Medicine MD-Ph.D. student Jessica Cerdeña, MPhil.

Cerdeña is referencing her co-authors, Howard University Ph.D. student Marie Plaisime, MPH, and Yale Emergency Medicine physician Jennifer Tsai, MD, MEd—and their article, From race-based to race-conscious medicine: how anti-racist uprisings call us to act, recently published in The Lancet.

Cerdeña, Plaisime, and Tsai had submitted their article to The Lancet, after the medical journal, in June, announced a commitment to action following George Floyd’s murder and the Black Lives Matters protests. “Our task is to educate ourselves and others about racism. We must support Black and minority ethnic health workers,” The Lancet stated. It pledged “to use science as an instrument for social change,” in part through “the research we publish, the authors we commission, and the individuals we choose to profile and recognize.”

Cerdeña, Plaisime, and Tsai, according to Cerdeña, saw this commitment to action as an opportunity “to speak to longstanding issues of race-based medicine.” In their article, the authors state that medicine “is an institution of structural racism” and that a pervasive example of this is race-based medicine, “the system by which research characterizing race as an essential, biological variable translates into clinical practice, leading to inequitable care.”

The authors seek to shift from race-based to race-conscious medicine, “to promote conscious, antiracist practices over unchecked assumptions that uphold racial hierarchies.” Additionally, as Cerdeña describes, “we had seen other work discussing issues of racism in medicine and race-based medicine, but we had not seen any actionable tools that proposed a way forward. We hope that our work provides a model for how to dismantle race-based medicine and instead address the health consequences of structural racism.”

The authors note that during European colonialization, “race was developed as a tool to divide and control populations worldwide. Race is thus a social and power construct, with meanings that have shifted over time to suit political goals, including to assert biological inferiority of dark-skinned populations.”

They describe how despite “the absence of meaningful correspondence between race and genetics, race is repeatedly used as a shortcut in clinical medicine”—and how medical education often trains students to continue this harmful practice. For example, “race is often learned as an independent risk factor for disease, rather than as a mediator of structural inequalities resulting from racist policies.” When health disparities are presented without context, students learn to associate race with disease conditions, for example, cystic fibrosis and hypertension, and develop dangerous stereotypes. Clinical rotations often reinforce these lessons, when students are taught that race is relevant to treatment decisions, and because of power dynamics, cannot “question the racialized assumptions of their supervisors.”

The authors argue that health inequities would be reduced if there was a shift to race-conscious medicine, which emphasizes “racism, rather than race, as

Advocating for Nursing Home Workers in Pandemic

Nursing home workers face a higher risk for COVID-19 than most Americans, providing essential care in hazardous conditions and at lower pay than they deserve, says David Grabowski, a professor of health care policy at Harvard Medical School. Giving them a living wage, decent benefits and adequate personal protective equipment is not only the right thing to do, it would help keep long-term care residents safer amid the pandemic, too, he says.

Grabowski, whose “day job” is doing research on the U.S. long-term care system, says it’s time to rethink the underlying structure of nursing home reimbursement.

Since the pandemic began, Grabowski has taken on a slew of new roles: serving on a Centers for Medicare & Medicaid Services task force called the Coronavirus Commission on Safety and Quality in Nursing Homes, testifying twice before Congress and writing op-eds aimed at advancing the cause of nursing home workers and residents alike.

Thanks to COVID-19, nursing home workers now have the most dangerous job in America, Grabowski and co-authors declared in a July 28 opinion piece in the Washington Post. Using CMS nursing home data, they determined that more than 200 COVID-19 related fatalities will occur per 100,000 nursing home workers if overall deaths continue at their current pace over a full year.

For their brave and selfless response in continuing to work in an already physically and emotionally demanding job – now with the added danger of coronavirus exposure – nursing home workers like nurses, certified nursing assistants and support staff should receive national hazard pay, Grabowski and co-authors argued.

Direct care staff at nursing homes also need access to good-quality personal protective equipment to prevent virus transmission, free access to coronavirus testing and the ability to make choices about when to stay home when they’re sick without fear of income loss, they added.

Grabowski’s career direction was shaped almost serendipitously when he was a Duke University undergrad in the early 1990s. “I had an adviser who said, ‘We should think about this as a project for your senior thesis,’” he recalls. “To be honest, I really knew nothing about long-term care or nursing homes. I ended up doing the project and it was everything that interested me about economics and public policy – only more so.”

The challenges faced by long-term care facilities, residents and caregivers soon captured Grabowski’s attention. “I ended up doing my dissertation on Medicaid payment and nursing home quality,” he says, Since then, he adds, “Basically, I’ve been doing this research on this area without realizing we would ever have this kind of pandemic and this kind of situation.”

Location – of the nursing home itself and where workers live in the surrounding area – plays an important role in the COVID-19 outbreaks, according to studies conducted nationwide. That includes findings on Cleveland, Detroit and New York City from Grabowski and colleagues, published June 24 in JAMA.

In June, Grabowski was named to the CMS task force to help