The Forward Movement: Amplifying Black Voices on Race and Orthopaedics-Disparity Studies Should Not Ignore America's Racial History.

Abstract

Our patients and the public at large carry high expectations for surgeons as effective problem solvers. Rightfully so. Identifying the root cause of a problem and efficiently working to resolve it are both prerequisites to the successful practice of orthopaedics. This is stressed upon us through the many rites of passage in our training. We take personal pride in it. And yet, when asked to apply the same level of discernment to racial health disparities, we fall dreadfully short. We have not successfully applied our immense insight to a public-health crisis staring directly in our collective face. The societal impact of fragility hip fractures in older adults is tremendous. By some estimates, the 1-year mortality rate after a hip fracture may reach 20% [6]. Many patients suffer decreases in fine motor, mobility, and cognitive status after hip fracture treatment [2]. Moreover, the societal cost of hip fractures has been estimated as high as USD 20 billion per year [3]. And as is commonly the case in the United States healthcare system, Black patients are at disproportionately higher risk for poorer outcomes after hip fracture. Black patients with hip fractures wait longer for their radiographs [1] and for their operations [1, 7]. Perhaps not surprisingly, they’re also more likely to experience complications following this severe injury [1, 4, 7]. These disparities suggest an access-to-care issue. What is its root cause? Studies on healthcare disparities often point a finger at unconscious bias and suggest the importance of a more diverse physician workforce. All good thoughts. But I challenge our field to take a closer look. By the time an older patient arrives in the emergency department with a hip fracture, a host of societal factors have already helped to put her there. And until there is a better understanding of the role race plays in that trajectory, orthopaedic surgery will continue to undertreat and mistreat Black patients. A critical evaluation of America’s racial past provides needed perspective. In the early 20th Century, millions of Black American families migrated from the rural South to urban centers of the Midwest, West Coast, and Northeast to escape the racial terrorism of the Jim Crow South, in what sometimes has been called the Great Migration [5]. Unfortunately, in these new locations, families were subjected to the same racism, albeit in a different form. The response to the influx of Black Americans in urban centers was systematic segregation. Through tactics such as redlining, legal and illegal methods were used to relegate Black families into the least-desirable parts of town. Subsequently, employment opportunities and access to public services were systematically removed from the segregated Black neighborhoods. The end result was the unfair and methodical exclusion of Black families in urban centers from important opportunities. The effects of these actions are felt to this day and are reflected in disparities in employment, housing, access to nutrition, and, of course, access to healthcare. This did not occur by accident or misunderstanding. So to say that Black patients in a Baltimore hospital waited longer for radiographs or hip fracture repair [1] without giving this historical context is inadequate. It is inadequate unless it is paired with a comprehension of the intentional societal efforts to marginalize the Black Americans of that community. It is inadequate unless it acknowledges the direct hand that structural discrimination has played in limiting Black patients’ access to expedient hip fracture care. It is inadequate until these realizations are utilized to reverse the effects of systemic racism. We need to change the way we frame the discussion of racial healthcare disparity in our orthopaedic literature. When we note disparate outcomes for Black patients in our investigations, we need to make it clear that this is not a matter of happenstance. We need to discuss the historical and societal factors that brought them about. The way forward can take many different forms (acknowledgement in discussion, extended discussion via commentaries, in-person topic discussions). But at the very least, in the study itself, the Discussion section of an orthopaedic health disparity study should address the how and the why or risk dehumanizing the people who are suffering. Out of respect for the communities that have been hurt, we must acknowledge that these findings are the direct results of intentional historical action and inaction. The clearer the picture we can paint of the root-cause of the problem, the more effectively we can partner with the public to bring it to an end.