Neko Upson doesn’t have to wonder whether she’s making a difference for her patients. She sees it when she walks in the room and their tension drains away.
“They see someone who looks like them, and you can see them relax,” she said.
Upson said she’s one of only four certified nurse midwives in Denver who are Black. While her white colleagues also can provide high-quality care, they have to work to break through the distrust that many patients of color have in the health system, while people from the same background have an easier time forming a relationship, she said.
In Colorado, as is the case nationwide, Black and Hispanic people working in the health field are overrepresented in lower-paid jobs, like aides and support staff, but underrepresented among doctors, nurses, midwives and other jobs that pay more and require more education.
As of 2021, about 1.4% of people working as health care providers in Colorado were Black and 8.2% were Hispanic, according to data from the U.S. Census Bureau. In contrast, about 7.5% of those working in “health care support” were Black and 28.2% were Hispanic. Black and Hispanic people make up about 4.7% and 22.3% of the state’s population, respectively.
Providers, advocates and corporate philanthropic organizations are trying to diversify the state’s base of health care providers, both in the hope it leads to better outcomes, and because there simply aren’t enough people of any race working in these roles.
While it’s possible for providers to give empathetic, effective care to someone of any race, studies have found benefits to Black patients from being treated by Black providers.
A study of more than a million births in Florida found that Black newborns were about 39% less likely to die if the doctor overseeing their care was of the same race. Black adults also tend to live slightly longer in areas with more Black doctors — though it’s difficult to know if that’s because they receive better care, or because of other factors.
When patients have a provider who looks like them, they’re more likely to trust their doctor, and in the case of kids, more likely to see health care as a career option, said Dr. Johnny Johnson, a retired obstetrician who mentors medical students through the Mile High Medical Society, a Black physician group.
“It makes just a world of difference,” he said.
Even when a group is well-represented in health care as a whole, it can sometimes be a struggle to find providers who are a cultural match. For example, while Asian Americans make up a larger share of doctors and other high-paid professions as a whole, they’re underrepresented in the mental health field, according to the Health Resources and Services Administration.
Even U.S. Surgeon General Vivek Murthy reported it was a struggle to find a provider who was familiar with South Asian cultures when family members needed psychological help. Health systems need to do more to hire and support providers of color, which will then encourage others who are wondering if the mental health field has a place for them, he said.
“Our equity goals should be on par with our financial goals,” Murthy said during a stop in Denver earlier this year.
Upson said she only knew that midwifery was an option because the provider she saw when she was a teenager happened to be a midwife. Now, she occasionally speaks at high schools and nursing schools to get students thinking about the field.
While midwifery has a long history in the Black community, not many people know what certified nurse midwives do, Upson said. In Colorado, they must complete a graduate degree and practice in hospitals. While much of the job focuses on offering prenatal care and assisting with low- to medium-risk deliveries, certified nurse midwives also can provide routine gynecological care.
“You don’t know it’s an option, and if you don’t know, you don’t go to school for it,” she said.
Indra Lucero, founder of the nonprofit Elephant Circle, said they’re trying to diversify the maternal health field by focusing on careers that don’t require as much specialized education.
The group has held classes for aspiring doulas, focusing on recruiting immigrants, people of color and LGBTQ people. A doula acts as an advocate and guide during pregnancy and birth, and people who go on to work as certified professional midwives — who work in homes or birth centers — often get their start there, they said.
“We need low-barrier entry points,” Lucero said.
Students, providers need support
Ideally, students would meet and learn about people of color working in science and medicine throughout their whole education, since kids can quickly get the message those subjects aren’t for them if they don’t see themselves represented, or if their teachers don’t think they’re smart enough, Johnson said.
The Mile High Medical Society has been focusing on outreach to students at the University of Denver who are interested in health care, as well as mentoring those who enroll at the University of Colorado School of Medicine, he said.
A study of more than 81,000 people found that Black, Hispanic and American Indian students who took the standardized test for medical school faced more barriers to getting in. They were more likely to report they couldn’t afford help preparing for the test, that their parents hadn’t attended college, or that their advisers discouraged them from applying to medical school, which contributed to lower acceptance rates.
Acceptance to medical school also correlates strongly with family income, and Black, Hispanic and American Indian families are less likely to be wealthy than white families.
Getting students into medical school is only part of the battle, though, said Dr. Terri Richardson, a retired internal medicine specialist and member of the Mile High Medical Society. The group “adopts” students at the CU School of Medicine, taking them home for holidays and holding social events. For Black students who didn’t grow up in Colorado, it can be difficult to find where they belong, because the Denver area doesn’t have obvious Black neighborhoods, she said.
“The students need people they can connect to and bounce things off of,” she said. “Our organization isn’t large, but we’re trying to do a little piece.”
Perhaps the most helpful thing they do is help students to handle discrimination if they encounter it, Johnson said. For example, larger Black men can be labeled as intimidating even though they’re not behaving aggressively, and responding in the wrong way encourages that label to stick and causes more problems, he said.
There has been some progress over the decades in making education and medicine more inclusive, but students are still reporting that teachers ask if they’re in the right class when they take advanced math and science, Richardson said.
“I’m discouraged when I hear young people saying (they heard) some of the things I heard,” she said.
Rasheeda Ouedraogo, a school psychologist in the Denver area, said that the emphasis has traditionally been on bringing more people into the health field, rather than supporting those already working in it.
School-based mental health workers often struggle when administrators don’t understand their role, and those who are people of color are more likely to have their expertise dismissed, she said.
For example, at a meeting to discuss a student who needed an individualized education program for a disability, Ouedraogo said she raised concerns about friction in the student’s home life.
“I think it was a science teacher that said, ‘You don’t have to listen to her. It’s OK if you don’t get along with your son,’” she said.
The other people around the table didn’t say anything, and the parent dismissed her efforts to talk more about how a positive relationship helps students to thrive, Ouedraogo said.
“I would love to say that’s rare, but it isn’t,” she said.
Some people leave for private practice or go to other settings, but those who stay do it because they know students need someone advocating for them, Ouedraogo said. Still, it’s challenging to their mental health when they know they could face retribution if they raise something that makes people in authority uncomfortable, like disproportionate discipline for kids of color, she said.
“It’s almost like we’re falling on the sword daily,” Ouedraogo said.
“We’ve never been great at growing our own”
While the role of race might be most obvious when counseling a patient about something personal like mental health, every medical field benefits when it mirrors the community, because patients have greater trust in someone from the same background, said Adeeb Khan, executive director of the Delta Dental Colorado Foundation.
The foundation recently announced grants to four colleges to create slots for about 75 new dental hygiene students, with some starting new programs and others adding a “second shift,” he said.
The number of people working as dental hygienists has largely stagnated since 2020, and about 92% of dentists who were trying to hire hygienists in March 2022 said it was challenging to recruit people, according to the American Dental Association.
The group didn’t release a racial breakdown of hygienists, but about 98% are female, meaning there’s an opportunity to grow the workforce by reaching young men. That’s particularly important for people from cultures where it’s not considered appropriate to receive medical care from someone of the opposite sex, Khan said.
The foundation originally thought the best way to increase the number and diversity of workers would be to offer scholarships, but with so few programs, the impact would be limited, Khan said. The schools they chose already serve significant numbers of students of color, and have plans to recruit a diverse group of aspiring hygienists, he said.
“They get a lot more applicants than they have slots for,” he said.
The foundation is also working with high schools and nonprofits in rural areas to encourage a variety of younger people to think about dental hygiene as a potential career path, since most people who go into oral health know someone who works in the field, Khan said.
But Colorado needs to do more to fund programs training people for in-demand careers, and to help them avoid or pay off student loan debt, he said.
“A lot of our success as a state has been in getting educated people to move to Colorado,” he said. “We’ve never been great at growing our own.”
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