Racial Health Care Disparities in

Racial Health Care Disparities in the U.S. The oft-proclaimed “best health care system in the world” isn’t accessible to all Americans

BY MOHAMMED MOINUDDIN

The Great Depression of the 1930s, which caused severe socioeconomic stress throughout the U.S., precipitated the surfacing and escalation of longstanding racial tensions between Whites and Blacks.

During the ensuing massive unemployment, poverty, diseases and political unrest, crime and violence increased exponentially. Politicians tried hard to lessen the racial tension that continued throughout the 1930s.

In 1938, Frederick Keppel (president, Carnegie Corporation) invited Swedish Nobellaureate Gunnar Myrdal (professor of sociology, University of Stockholm) to prepare a report on Black-White friction. After traveling all over the country to talk to various communities and their leaders and interview people in responsible positions, he wrote and published his approximately 1,400-page “An American Dilemma: The Negro Problem and Modern Democracy” (1944). In this book, which became a well-known reference on racism, he wrote, “Area for area, class for class, Negroes cannot get the same advantage in the way of prevention and care of disease that Whites can. Discrimination increases Negro sickness and death both directly and indirectly, and manifests itself, both consciously and unconsciously” (p. 172).

For the first time, many Americans became aware of racial preference in health care.

The Civil Rights Act of 1964 (Title VI) further raised consciousness among health care workers so much that by the 1980s and 1990s, the number of racial disparity-related articles appearing in the medical literature reached more than 200 on the subject of heart disease alone.

Congress took note, and in 1999 assigned the Institute of Medicine (IOM, now the National Academy of Medicine) to specifically assess the differences in health care due to bias, discrimination and stereotyping, in addition to the known causes, and to recommend how to intervene and eliminate them.

Consequently, IOM appointed a 15-member commission composed of physicians, lawyers, nurses, psychologists, sociologists, scientists, health administrators and economists. They spent three years reviewing data from medical literature, interviewing the authors to validate their observations, traveling nationwide to talk with community and organization leaders and conducting several workshops. Another panel of 11 experts then reviewed this report. After two IOM-appointed experts reviewed it once again, it was published: “Unequal Treatment — Confronting Racial and Ethnic Disparities in Health Care” (https://www. ncbi.nlm.nih.gov/books/NBK220358/). A summary of this rigorously scrutinized report on Black-White health care disparities is provided below. Cardiovascular Diseases. Heart disease, the number one cause of death in the U.S., has the most data as regards health care disparities. The IOC found that Blacks are less likely to undergo cardiac catheterization (a “gold standard” invasive procedure that diagnoses coronary artery disease) when the disease is clinically suspected. If they undergo catheterization, they are less likely to receive revascularizing procedures such as angioplasty, stenting and atherectomy, or drugs such as beta-blockers (commonly used for angina) or thrombolytic therapy (clot dissolving medication) and Aspirin (used for prophylaxis). A meta-analysis of 25 studies showed that these differences were due to known factors, bias and discrimination. In 2000, the New England Journal of Medicine and Social Science and Medicine published two studies that identified bias, discrimination and stereotyping as the causes of health care disparities, in addition to known factors.

Between 1993-95, they studied 938 patients at the Cleveland VA Hospital for cardiac catheterization. The cardiology fellows would present patient data in the patient`s absence to a panel of cardiologists and heart surgeons. Race was not specified. When the staff physicians were unaware of the patients’ race, no difference was found with reference to the incidence of catheterization. This impressive study emphasized the role of race in clinical decision-making.

Kidney Diseases. The incidence of end-stage kidney disease and diabetes is higher among Blacks and Native Americans, and yet they are less likely to receive kidney transplants or be put on the waiting list. When they are, their waiting period is longer. In one dialysis center where 67% of the patients were Black, 64% of those who received kidney transplant were White. Within the first year of dialysis, in a national sample 30% of Whites and 13.5% of Blacks were placed on the transplant list. The reasons for such a disparity included patient preferences, biologic factors such as immunologic problems, disease severity and bias. It was

concluded that relatively less time was spent such as the Tuskegee Study of Untreated Syphilis on explaining kidney transplantation to Blacks. in the African American Male.

AIDS and HIV. Prophylactic treatment and In 1932, the U.S. Public Health Service bronchoscopy (a diagnostic test that visualizes (USPHS) — a division of the Department of the airways and lung through a tube) were less Health and Human Services — launched a study available to Blacks. Among gay and bisexual men, to determine the natural history of untreated syphWhites were 60% more likely to get the anti-ret- ilis. Choosing Alabama’s Macon County as the roviral drug AZT. research site because of its very high concentration

Cancer. Cancer is a complex multifactorial of indigent people suffering from syphilis, they disease and therefore less frequently mentioned recruited 199 patients and 201 normal controls. as a cause of racial bias. Biologic factors, cultural The study continued for 40 years until New York beliefs and socioeconomic reasons are often men- Times reporter Jean Hiller visited in 1972 and, after tioned as the cause of racial disparities. However, gathering the relevant data, stated in her July 26, soft data indicates that discrimination may also 1972, front-page article: “Syphilis victims in the be a factor. For example, older Black women were United States study went untreated for 40 years — stand why people have such biases, one must know the underlying the longest non-therapeutic experiment on human beings in medical history.”

THE TUSKEGEE STUDY CAME TO SYMBOLIZE The Tuskegee study came to symbolize racism in medicine, ethical misconduct in human research

RACISM IN MEDICINE, ETHICAL MISCONDUCT and government abuse of vulnerable people. The

IN HUMAN RESEARCH AND GOVERNMENT government subsequently ordered the study stopped — after 128 patients had died, 40 wives were infected ABUSE OF VULNERABLE PEOPLE. and 19 children had contracted the disease. Considered the darkest chapter in American medicine, this reality caused deep psychological consistently less likely to undergo mammograms, Black patients’ AIDS and the refusal of some of them to take the flu vaccine. colorectal cancer was treated less aggressively, Blacks had a lower However, such problems are not inevitable. This cycle of biasincidence of sigmoidoscopies and were less likely to undergo sur- mistrust-bias needs to be broken. Due to the system’s flexibility, gery for lung cancer after controlling for age, gender, stage disease, some meaningful progress toward equality has been made. For comorbidity and income. example, the first clause of the Constitution — Blacks are only

Similar disparities were also observed in other diseases. three-fifths human — was amended in 1867 and they were given

They recommended: the right to vote. ■ Increased awareness among health care workers and the general The gap between screening mammograms in the 1990s has also public about the causes of racial disparities. disappeared. These and other changes occurred because of educa■ Defragmented insurance plans — having one uniform plan tion and widespread knowledge of the inequalities. But much more for all to ensure equal treatment. still needs to be done. The overall mortality rates among Blacks ■ More minorities in the health care system. were 60% higher than Whites in 1950; they were the same in 1995. ■ Cross-cultural education — teaching health care providers Health care inequality in terms of heart and other diseases continue. about cultural differences in peoples of different ethnicities, reli- Minority individuals suffering from fractures are prescribed fewer gions and cultures. analgesics (painkillers) than Whites. ■ More interpreters to ensure accurate communication between The IOM report recommends several steps to remedy this non-English-speaking patients and health care workers. ongoing problem: increase public awareness; educate physicians, ■ More research on the causes of disparities and how to intervene. health care workers and the public about these disparities; and

The IOM committee, which included specialists with no self-in- repeatedly emphasize education as the most powerful means to terest or political agendas, approached the subject meticulously achieve balance. and went through it methodically. After a thorough review of the IOM has done an excellent job of researching this subject. Its literature, they found robust evidence that in addition to known landmark “Unequal Treatment: Confronting Racial and Ethnic causes of racial disparities, bias, discrimination and prejudice con- Disparities in Health Care” (2003) has raised the consciousness tribute significantly to mortality and morbidity among minority of the American Medical Association, the National Institutes of populations; that bias may be conscious or unconscious, institutional Health, the American College of Physicians, the Robert Wood or individual, overt or occult — however, it is often subconscious Johnson Foundation, the American Heart Associations and several and subtle; that bias is difficult to diagnose or quantify; and that others. All of them are working to eliminate racial disparities in health care workers are frequently in denial. health care and ensure system-wide equality and equity so that

Interestingly, some Blacks think AIDS was created to wipe out the everyone enjoys health care justice in this country of which we Black race. This raises the problem of bias on both sides. To under- are so proud. ih scars among Blacks and led to their view about perceptions. Sometimes, bias may be a response to an earlier bias, Mohammed Moinuddin, MD, is a nuclear medicine specialist in Memphis, Tenn.