Nikki Mahendru’s mother didn’t go to the gynecologist for 45 years — and when she did, she regretted it. Ms. Mahendru felt “decades of anxieties and hesitancy reduced to five minutes of brisk interaction with her provider,” and left convinced that the “realm of women’s health was just not for her.” According to Nikki, a Duke University undergraduate, her mother’s “trust in the system was lost.”
Mahendru joined Dr. Megan Huchko, the director of the Duke Center for Global Reproductive Health, and Dr. Chemtai Mungo, a Fogarty Global Health Fellow and OB-GYN doctor, on the Center for Global Women’s Health Technologies’ October 20 panel “Impact of Race and Socioeconomic Status in Women’s Health and Gynecology.” The panel was moderated by Ashley Deans and Alexandria Da Ponte.
Mahendru went on to detail an experience she had in the clinic with Carmen, a patient who spoke only Spanish and was also new to the gynecologist. The medical translator and Mahendru learned her story: she had been in pain for a year but had kept quiet due to money problems, had worked most of her life to send her kids to college, and was learning English via Rosetta Stone. With the details of Carmen’s story and an “equitable working relationship,” Mahendru and the translator could relay Carmen’s previous history to her provider. But Carmen’s provider knew only of her condition.
Mahendru thinks gynecology done right has the potential to help women love their bodies and take care of their health, but gynecologists must earn the trust of their patients: “Acts of listening help bridge disparities.”
Dr. Huchko stated that throughout history, a male-dominated healthcare landscape saw the depiction of menses as ‘dirty,’ terms like ‘hysteria,’ and an overall lack of female control. The “father of gynecology” James Marion Sims exploited Black women in his development of the field, using unanesthetized slaves as subjects of experimentation. In general, Dr. Huchko sees a trend: “The lessening or decentering of women in women’s health corresponds to more discrimination.” In addition to the decentering of women, Dr. Huchko said that structural and individual factors “produce outcomes that prevent women from getting the care they need.” Like Mahendru, she identified trust as a central issue.
Dr. Huchko cited an experience in which she bore witness to the unattended consequences of racial bias in medicine. In Niger to repair women’s fistulas, which occur due to lack of postpartum care, Dr. Huchko felt she was attending to the downstream symptom of a much broader issue. She felt uncomfortable when the urogynecologist on her team ignorantly praised Sims without acknowledging his problematic history. Then, she saw this ignorance firsthand.
Making a false assumption about the nature of the case, Dr. Huchko’s team chose to operate on a woman with a mass in her bladder. During the surgery, they realized the mass was a malignant tumor. With an unbiased eye and a complete exam and workup, this would have been clear. But because the team was looking at these women as “one-dimensional,” a woman with stage 4 cancer was subjected to a very invasive surgery that worsened her quality of life.
Dr. Huchko experienced a similar lack of structural competency during her residency, where colleagues openly racially profiled people and overtly discussed disparities in pain tolerances among different ethnicities. Since then, “things have changed,” and she embraces this new culture of “being patient centered, exploring our own biases, and [having] zero tolerance for racial profiling.” She stresses the need for personal education and accountability alongside systemic change. Eventually, this will lead to women feeling “respected, seen, and heard.”
Coming to the US from Kenya, Dr. Mungo quickly came to appreciate the “sheer magnitude” of structural racism and its impact on health and healthcare. Dr. Mungo explained that “mutually reinforcing systems of disadvantage” for people of color, such as food deserts, are both the result and cause of healthcare disparities and result in enduring legacies of disadvantage.
Dr. Mungo also observed that with healthcare in the US being so economically driven, the best care is often directed at those with racial and socioeconomic privilege. When she worked in a high resourced (read: white, wealthy) hospital, access to uterus-saving equipment such as interventional radiology meant that she only did one hysterectomy in four years. Doctors at the hospital also came in on weekends to get a person with cancer into the OR immediately.
Now, working at a “safety net hospital,” Dr. Mungo sees a stark difference. With non-existent interventional radiology and more part-time, “less invested” employees, Dr. Mungo has done three hysterectomies in three years — a 75% increase — and sees patients with time-sensitive conditions wait much longer before surgery. This “separate and unequal access to resources” is a cause for concern.
Dr. Mungo also stressed the need to make practices “safe places” for patients of color by increasing minority representation. Dr. Mungo explained that while Black physicians make up only 5% of doctors and 3% of faculty, there is strong evidence that patients who are cared for by someone of their own race or ethnicity have better outcomes. “We live in a racist society,” Dr. Mungo stated, “so we need specific anti-racist policies.”
Dr. Mungo also acknowledged that healthcare providers work within “templates” like 15 minute appointments, and posed the closing question, how can we make patients feel safe and heard within the constraints of modern medicine?
Answering questions from the audience, Dr. Mungo and Huchko discussed medical algorithms that are based on race, like the VBAC calculator and GFR.
Dr. Mungo indicted these algorithms as “an example of how institutionalized some [racial] biases are.” There is “no concrete evidence” on why these corrections for race — which typically act to reduce the probability of success for a procedure or favorability of an outcome — exist. Dr. Mungo would urge providers “not to stop at, ‘well, African Americans have an increased risk of diabetes.’ Ask why. Have them explain food deserts… and structural and environmental racism.”
Dr. Huchko stated that giving aspirin throughout pregnancy reduces preeclampsia, and is thus traditionally offered based on risk factors for preeclampsia, like low socioeconomic status and African American race. Sometimes, healthcare providers may not be able to address these risks without the acknowledgement of race as a risk factor. Dr. Huchko is right, African American women are at a higher risk for preeclampsia, and ignoring this correlation would probably do more harm than good.
But per Dr. Mungo’s appeal, providers must interrogate these associations more deeply — and be ever anti-racist in their efforts — if they are to create the safe spaces and trusting relationships that Mahendru, Dr. Huchko, and Dr. Mungo each hope to see.
This article was published in Duke Research