Mitigating Mistrust

Illustration: two people of light and dark skin sitting on opposite sides of a does-not-equal sign.

As calls increase to correct longstanding inequities in healthcare, pharmacists are exploring ways to improve training and practice to better serve marginalized groups.

By Joseph A. Cantlupe

While discriminatory practices in healthcare settings have existed for decades, the COVID-19 pandemic further revealed inequities rooted in the longstanding unequal treatment of minorities in this country. Academic pharmacists are committing to racial justice, beginning with changes to improve minority enrollment at colleges and universities and by seeking to boost minority faculty numbers. They also say there should be significant curriculum revisions to address inequities, and new language and cultural opportunities in pharmacy schools to better serve the health of diverse communities. Pharmacy schools can help lay the groundwork for needed changes within the profession to improve outreach and care to patients in minority groups.

These issues were raised in a recent AACP webinar, “Mistrust in the U.S. Healthcare System Among Marginalized Groups,” which included a panel of academic pharmacy leaders representing minority groups who challenged leaders within the profession and elsewhere to overcome discriminatory practices. Pharmacists have been doing more to provide innovative practice models and services that directly engage the patient in ways that will decrease health disparities, said Dr. Hope Campbell, associate professor of pharmacy practice at Belmont University College of Pharmacy, but “you still have individuals experiencing racism that is baked into the system.”

During the pandemic, pharmacists have helped expand access and increase public education about the vaccines, she said. “They became more involved in public health, ran mobile clinics, did contact tracing, collaborated with local authorities and nonprofits.” Over the years, however, decisions, policies and procedures have led to disparate outcomes. “We have this historical reference that has carried over and we do see the fallout of that today,” Campbell said, specifically noting discrimination against Blacks beginning with slavery, Jim Crow laws and racist healthcare policies. "The same things that occurred in the past continue. We now have some rules and laws that protect us, but it has not removed the barriers,” she continued, referring to systemic and structural racism against the Black community and other minority groups, which are reflected inside and outside the classroom.

Lack of Diversity

Campbell coauthored a 2016 study that showed that enrollment within most colleges of pharmacy did not reflect the racial and ethnic diversity of the counties in which they are located. The report found that Asian students were overrepresented in most colleges of pharmacy, while Black and Hispanic students were underrepresented, she said. Since then, the situation hasn’t changed.

“To meet the healthcare needs of an increasingly diverse population, each institution should establish a strategic plan for increasing diversity and evaluating and adopting best practices,” Campbell wrote. Pharmacy schools must encourage students of color to go into the pharmacy and “remove any barriers, policies or procedures that we have in place that might be a huge obstacle to a marginalized community member.”

Dr. Carmen “Skip” Clelland, senior public health advisor to the federal Health Resources & Services Administration (part of the Department of Health and Human Services), said pharmacy schools must address myriad issues, among them “the role of pharmacy and the training of pharmacists, the general impact of drug therapy and the social determinant of health impacts on populations.” Among other things, the country lacks effective data collection systems to measure inequities, he said.

“There are challenges with the health data measurement specifically within the minority community,” noted Clelland, a member of the Cheyenne and Arapaho Tribes. “There are unique differences you might see in the general population as far as race or ethnicity. There is the Black population and that may be mixed with American Indians. And part of an American Indian tribe may not be of a singular race. We have to identify and collect data that is meaningful.” It is important to consider genotypes and phenotypes, for instance, in clinical decision making and possible adverse outcomes of medications.

He noted that American Indians and Alaska Natives have suffered inequities related to discriminatory practices. As those unfolded over the years, many people lost faith in the government and the healthcare system, Clelland said. As a result, minority groups must deal with trust issues that impact their healthcare. “I think a lot of the mistrust, especially among American Indian and Alaska Natives, has to do with prior mistreatment by the federal government. That had a negative impact on the general lifespan of American Indians as well as social status and economic conditions.”

We have a long way to go to ensure that we have that data and what it looks like within different populations. In pharmacy education, what I often see is in terms of silos, you’ll learn about a community and check it off, then learn about Hmong and check that box, or learn about the LatinX community and check that. But you will meet the patient and there’s not one checkbox, there may be multiple identities there.

Dr. Kajua Lor

Dr. Kajua Lor, associate professor, chair of the Department of Clinical Sciences at the Medical College of Wisconsin Pharmacy School, speaks Spanish and also worked in a LatinX community where many of her patients believe she is Chinese, although she is of Hmong ancestry. The Hmong are members of an ethnic group in Southeast Asia that have not had a country of their own. During the Vietnam War, Hmong in Laos partnered with American forces to fight Southeast Asian communists but were left behind after the U.S. pulled out of Laos, forcing many to flee or be killed.

Lor pointed out that Asians are sometimes lumped into one category in calculations of their health needs during data collection, which ignores people from individual countries and different communities in Asia. Academia should lead the way in collecting and synthesizing data that would reinforce the needs in each country, said Lor, who echoed Clelland’s concerns about data collection flaws.

“I do think aggregating data is necessary,” Lor said. In some states, there may be areas where, in a manner of speaking, “Asian Americans are all healthy, with no chronic disease and no issues with cancer,” but that belies the truth hidden in each community, she explained. “We have a long way to go to ensure that we have that data and what it looks like within different populations. In pharmacy education, what I often see is in terms of silos, you’ll learn about a community and check it off, then learn about Hmong and check that box, or learn about the LatinX community and check that. But you will meet the patient and there’s not one checkbox, there may be multiple identities there.”

Curriculum Changes Needed

Expanding curricula that opens the door for more minority students is essential to provide potential academic pharmacy advances in equity, Campbell said. Academia can step up to address inequities through various curriculum changes, such as expanding anti-racism education and focusing on social determinants of health, structural racism and cultural competency.

“It’s important to educate ourselves about implicit and explicit bias, structural systematic racism, social determinants of health and the impact that these have on the care we deliver,” Campbell said. And that doesn’t stop with clinicians. “Educate patients about their care in a culturally and linguistically competent manner.” Collaborations should be established with “trusted community partners, respected figures and NGOs in marginalized communities to extend our reach.”

Clelland added that part of the expectation for student pharmacists is that they have the training to ensure they can prescribe the right drug for the right person, yet curriculum can be expansive in its reach into population health and the social determinants of health, “and what is the overall larger impact of looking at pharmacy’s accessibility,” he said. Pharmacy schools can better prepare students to differentiate the needs of populations, which is a true reflection of Americana, he said, such as in downtown Atlanta compared to its suburbs, or in the needs of the Hopi Tribe in Arizona compared to residents in New York City. “You rarely hear about pharmacy engaged in population health. When you come out of school, you are rarely prepared for that. Populations in different communities may not have the same needs or challenges.”

Too often, there has been a “recognition that the way we have been doing things in the past has always reflected what we should be doing,” Clelland pointed out. “The same thing happened when women were left out of the conversation and the questions were posed: how do we make sure women are added to research and are we addressing the community of women and getting them interested in research.”

Lor said she seeks to overhaul cultural competency training in pharmacy schools, “where learners are taught one culture and/or population at a time. This segmented training creates learners who lack the proper skills to develop structural humility and also allows for the perpetuation of racism, generalizations and stereotypes in patient care,” she said. Such a changed “structural competency framework” is a needed with a shift that “emphasizes cross-cultural understandings of individual patients.”

Lor is involved in a project called “Invisible Identities: Reimagining Cultural Competency Training for Health Professionals.” Those identities include veterans, people with disabilities, members of the LGBTQ community and people who self-identify as Hmong or other southeast Asian ethnic minorities. “We anticipate that our project will illuminate the impact of intersectionality and provide the skills to work with marginalized and invisible populations,” she said.

Another area that may improve outreach and thwart inequities is through language instruction. Lor is evaluating the ongoing and historical framework involving communication between pharmacists and Spanish-speaking populations, in which barriers remain and continue to lead to inequities. Health information through pictures and videos tailored to certain languages can play a vital role in opening up pharmacies to more diverse communities, she indicated, and those elements can be included in pharmacy instruction.

A pharmacist can wear a rainbow pin, for instance, to signify being open to LGBTQ+ communities, or another pin that “indicates the languages that you speak, such as ‘Hablo español’ (I speak Spanish) or ‘Kuv paub hais lus Hmoob’ (I speak Hmong), or even tailor the artwork in the clinic or pharmacy where you work,” she said. Pharmacists can also ask whether a patient prefers Spanish or English instead of making assumptions about language preference. “For invisible minorities like the Hmong, translation of labels is not enough, as many Hmong do not read and write in the Hmong language. Culturally tailored health information through pictures and videos is of utmost importance when words like ‘cancer’ do not exist in the community you are working with,” Lor emphasized.

Campbell said language needs within a local community should be evaluated and be taken up by a local university or college. They may “need to add medical Spanish or other languages if a large immigrant population is served by graduates,” she said. Institutions can expand offerings such as dual degree programs that allow students to earn a master’s in public health and social justice.

Underrepresented Minorities

Based on Census Bureau projections in 2018, the U.S. should have reached a point sometime within the past year when more than half of the nation’s children represented an ethnic or racial minority. However, Blacks, Hispanics and Native populations are underrepresented in health service professions such as medicine, dentistry, nursing and pharmacy. Of the total number of students enrolled in first professional degree programs for fall 2019, 17 percent were underrepresented minority students. White Americans received almost 50 percent of first professional degrees conferred in 2018–19. Asian Americans received 25.6 percent of the first professional degrees, according to the American Journal of Pharmacy Education.

The AJPE report indicated that nearly 15 percent of degree recipients were underrepresented minorities (Black or African American, 8.5 percent; Hispanic or Latino, 5.7 percent; Native Hawaiian or Other Pacific Islander, 0.3 percent; American Indian or Alaska Native, 0.3 percent). The pharmacy Academy has also lagged in hiring minority faculty, Campbell said. Pharmacy has been more successful than medicine and dentistry in recruiting Black faculty but falls behind dental schools in their representation of Hispanic faculty. New schools and religious-affiliated institutions include more Black and Hispanic faculty members. In 2013, Blacks comprised 13.2 percent of the U.S. population yet only 4.7 percent of pharmacy faculty. Hispanics were the largest minority group in the country at 17.1 percent, but they constituted only 2.9 percent of pharmacy faculty, Campbell’s study revealed.

Unfortunately, gaps exist in tracking the details of student populations in pharmacy programs, such as the number in residency programs, Campbell said. Although there is a distinct “paucity and scarcity of color” among people in residency programs and also an apparent lack of residency program directors, “we don’t collect that data,” she added. Attempts have been made to secure the data that would pinpoint specific breakdowns but they have been unsuccessful. An AACP report on affirmative action and diversity released in 2000 noted the need to track the number of minority students in fellowships and residences, but 20 years later this goal still hasn’t been met. “If it’s not measured, it is not important and we don’t know the impact. It is my goal to track students of color. It’s tough being the only [Black student] in a class or group. We need to make sure that faculty is as diverse as can be. There needs to be a wide net cast to catch a diverse class. Black faculty aren’t being utilized.”

It’s important to educate ourselves about implicit and explicit bias, structural systematic racism, social determinants of health and the impact that these have on the care we deliver. Educate patients about their care in a culturally and linguistically competent manner.

Dr. Hope Campbell

Schools have a chance to open the door for more minority enrollment, Campbell emphasized. This past year, first professional student pharmacist enrollments were down 2.9 percent compared to fall 2018. Minority-serving institutions continue to provide a significant number of pharmacists of color to serve the U.S. population. “They continue to produce what they were designed to produce—underrepresented minorities in the profession,” she said.

The webinar speakers laid out a broad role for pharmacists and educators to overcome racial and ethnic disparities. Clelland referred to the Department of Health and Human Services’ Healthy People initiative 2030 that provides a measurable framework and objectives to improve healthcare over the next decade, in which pharmacists can play key roles. “Pharmacists have a primary seat at the public health table,” Clelland said. “We should be the most successful public health providers out there. We’re the most accessible.”

Campbell added, “The fight for our patients must take us out of the pharmacy and into the streets, boardrooms and policy meetings. We need to influence the decisions that are being made that negatively affect our patients. Pharmacy must work to expand where they have influence and use their seat at the table for the good of their patients or leave the table.” She said she uses the acronym DECLARE when she thinks about how pharmacy can move forward on diversity issues: Diversity, Educate, Collaborate, Leadership, Advocate, Research and Empower.

“Self-awareness and understanding our own racial identity and implicit biases are key to grow in this space,” Lor concluded. “The pharmacy community should take a look from the balcony and examine the structures and policies that impact the communities we serve to truly address inequities. Growth in cultural and structural humility takes time and heart.”

Joseph A. Cantlupe is a freelance writer based in Washington, D.C.