Racial Inequalities in Healthcare

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The color line in America’s healthcare system has surfaced repeatedly in our ongoing series on race and class. Several recent government studies have underscored the pervasive inequalities in minorities’ access to care and in their overall health (e.g. the 2002 Institute of Medicine study on unequal treatment and the 2004 National Healthcare Disparities Report). It’s been obvious for decades that wealth level correlates strongly with healthiness and access to care. But even if you account for class differences, there are clear racial disparities. Some examples: blacks are 40% more likely to die of cardiovascular disease than whites; minorities are less likely to undergo bypass surgery or kidney dialysis/transplants; black women with breast cancer have shorter survival rates than white women. So this hour we’ll be trying to understand the enormous number of factors that play into all of this.

One is environment and lifestyle — living, for example, in a polluted inner city where healthy food can be difficult to find even if it were affordable contributes to high rates of asthma, obesity, diabetes, and cardiovascular disease, among other problems. Minorities are also disproportionately represented in prison populations, where infectious disease rates are extremely high. [UPDATE: As “The Angry Heart” — which nother recommended in the comments below — points out: the constant stress of coping with racism and/or living in a dangerous neighborhood can have a big impact on health.]

Then: minorities face barriers in access to healthcare. They are more likely to be uninsured, the hospitals that serve their neighborhoods may be of lower quality, they may not have adequate transportation to reach a hospital, they may not be able to afford time off from jobs to go see a doctor, they may feel intimidated by the system and avoid going to preventative appointments…the list goes on.

And finally: once they’re actually in the healthcare system, minorities may encounter language barriers, a frightening hospital bureaucracy, overt or unconscious racism, unequal rates of referrals to specialists, doctors who aren’t educated to deal with cultural differences that affect beliefs about health or ability to communicate health information…again, the list continues.

So what’s to be done and where do you start? We’re hoping our guests can tease this apart. Among the things we’d like to hear from you: have you encountered racial inequalities in healthcare as a patient? As a doctor?

Thomas LaVeist

Director of the Center for Health Disparities Solutions at the Johns Hopkins Bloomberg School of Public Health. Author of Minority Populations and Health: An Introduction to Health Disparities in the U.S.. More on Thomas LaVeist and the book here.

Dr. Joseph Betancourt

Co-chairs the Disparities Committee at Massachusetts General Hospital (MGH). Senior scientist at the MGH Institute for Health Policy. Was on the Institute of Medicine committee that produced the 2002 “Unequal Treatment” report. Practices internal medicine at MGH. Here’s a full bio.

Dr. La Mar Hasbrouck

Internal medicine physician at Grady Memorial Hospital in Atlanta, GA. On the faculty at Morehouse School of Medicine and Emory University School of Medicine.

Dr. Christian Arbelaez

ER physician at Brigham & Women’s Hopsital in Boston, MA. Just finished a Commonwealth Fund Fellowship in Minority Health Policy at Harvard Medical School. Went to New Orleans to help out after Hurricane Katrina.

Dr. Carol Scott

ER physician and on the faculty at the University of Maryland Medical Center in Baltimore, MD. Also works as a patient educator and advocate. Click here to read more about her.

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  • nother

    Jay Fedigan filmed a documentary on this subject called “The Angry Heart.” You can check out http://www.theangryheart.com for more info. He interviewed, among others, Cornel West, Dr. Camara Jones, and Dr. Nancy Krieger. If you can possibly contact Dr. krieger you will not be disappointed, she does not pull any punches. In the film, she talks about the study done where six white patients and six black patients go to the doctor with the same symptoms, the results will surprise you – or they won’t.

    Jay has been trying to put together a larger project called “The Color of Health,” a collaboration with Harvard University faculty members, W. Michael Byrd, MD, MPH, and his wife, Linda A. Clayton, MD, MPH. Authors of the Pulitzer-nominated volumes: An American Health Dilemma: A Medical History of African-Americans and the Problem of Race, and An American Health Dilemma: Race, Medicine and Health Care in the United States, Byrd and Clayton have collected 25-years of research into one of the most comprehensive libraries on African-American health and medicine known today.

  • Potter

    I saw the documentary. A very strong presentation and I agree about the interviews. Is Keith Hartgrove still alive?

  • liberal quaker

    I am a pediatrics resident at a major medical center. I spend some time in 2 clinics; one located in a wealthy suburban area that is predominantly white, and the other is a urban city clinic that draws from the local african american community. At the risk of promoting false stereotypes, I have discovered that there is a striking difference in the kinds of personal interactions that I have with each group of parents, and I must constantly monitor my thoughts so that I do not compromise care for my pediatric patients.

    During a well child check for shots….

    ….most wealthy parents cling to my every word of advice and ask questions about child development, safety, etc.

    ….most urban parents just want to get the shots and then get out the door; very little attention is paid to me, let alone my child-rearing advice. On several occassions I have waited for parents to finish cell phone calls while I was waiting to ask questions.

    In a situation where antibiotics for an ear infection may not be indicated….

    ….wealthy parents tend to accept my reasoning (based on the latest American Academy of Pediatrics guidelines) and are willing to forego antibiotics

    ….urban parents tend to see the withholding of antibiotics as a personal insult, with several calm discussions having ended with an outright accusation that I would be giving antibiotics to a white child in the same situation.

    In the physicians office….

    ….wealthy parents tend to quietly complain about having to wait too long, but that anger ends when I step into the room.

    ….urban parents tend to carry that hostility over into the visit, and are much less cooperative as if this was a form of “getting even.”

    During my physical exam….

    white kids, latino kids, and african american kids all have minds, hearts, and lungs. Thats the only kind of stereotypes I am interested in. It take a lot of my energy to keep calm when dealing with frustrated and angry parents, and this is energy that is best spent on taking excellent care of their children.

  • Katherine

    nother and Potter: we didn’t know about “The Angry Heart” — thank you for this — we’ll look into it.

    liberal quaker: these are exactly the sorts of anecdotes we’re hoping to get on the air to illustrate the larger point of the show and make it very concrete.

  • jc

    It would perhaps be interesting, to me anyway, if liberal quaker got some colleagues of different races to submit anecdotes of their experiences in similar circumstances.

  • Liz Tracey

    I don’t know if you’ve booked all your guests yet, but you might want to talk to Dr. George Weiner, the director of the Center for Health Equity at Cleveland State. He is an excellent source of knowledge on urban health care disparities. I can get you contact information if you’d like.

    As always, Radio Open Source rocks, in a non-musical intellectual way. 🙂

  • joel

    Would the believers in ID or Creationism be considered another race? Given that it is unlikely that enough vaccine effective for the avian flu N1H5 (?) virus will be available to serve more than a small percentage of the world’s population if a pandemic occurs, will the vaccine be denied the Creationists since this virus cannot evolve in their world to affect them?

    Cheers.

  • Griflet

    Thank you for this ongoing discussion, it’s the best I’ve heard in many years. You have already surpassed Bill Clinton’s effort. In the late ‘60s and early ‘70s I was part of an organization that attempted, as white people, to educate other white people about racism. Our focus was to get white people to oppose and correct the racist behavior of the white culture. We found that differentiating between attitudinal, behavioral; individual and institutional racism helped people understand the problem and focus their efforts more effectively. Often two or more of these components are present in any given situation.

    We usually think of racism as predjudice, individual attitudinal racism, the actual belief that non-whites are inferior. This is what Secretary Rice meant when she said she was sure race wasn’t a factor in what happened in New Orleans. There are reports though, that some lower level officials where heard saying things like “those people who didn’t evacuate brought their problem on themselves�. But generally, we picture some sort of honkie driving up in a share- cropper’s yard and laying on his horn because it’s beneath him to get out of his car or go knock on the door making the racism behavioral as well. If some of these types run the local ASCS office, they can prevent black farmers from getting the government subsidies available to white farmers, making the racism institutional as well as attitudinal and behavioral.

    When the subsidies change to favor large corporate farms even more, some of them run or owned by former smaller white farmers who received the subsidies, most of the small farmers left are black. “Racist� ASCS officials are no longer needed, the racist behavior of the state continues simply by providing subsidies that small farmers “don’t qualify for�. That in some areas these farmers are mostly black, becomes incidental. No one has to use the N word, there is no obvious racist intent, but the effect is still racist. mostly black farmers are disadvantaged. Now we have institutional, behavioral racism without racist intent. This has become the dominant form of racism in the U.S. Most black people understand that it’s still racism, most white people don’t.

    When we point out that inner-city schools are now run by black people, we ignore the history. Housing loans to WW II veterans were administered by States through banks that red lined. The tax base was hijacked to the suburbs, followed by the jobs and the best hospitals.

    White people who ask “Can’t we just forget the past and go on from here?� don’t understand how we got where we are. White pediatric residents aren’t going to get the respect they expect from many black parents regardless of how conscientious they are about not being racist. A black resident might be able to interrupt a cell phone conversation or convince a parent that a change for the better in the treatment of ear aches was not a racist plot. Rather than be offended by having his/her good intentions dissed, Liberal Quaker could learn more about racism and consider that his/her presence in the situation rather than a black resident is an insult of sorts, a reminder of 300 years of affirmative action for whites and that white parents unquestioning attention should also be questioned; after all we used antibiotics for otitis for years, contributing to the creation of resistant strains of bacteria and few parents questioned it.

  • liberal quaker

    “Liberal Quaker could learn more about racism and consider that his/her presence in the situation rather than a black resident is an insult of sorts”

    I do understand how we got where we were. Perhaps my mistake was in giving individuals the benefit of the doubt. The current generation of white medical residents grew up and went to school in a diverse environment, and for the most part we don’t care what you look like as long as you get the job done. When the residents at my program get together it looks like a miniature UN meeting. If some in the African american community feel that passive aggression against well-meaning people like myself (in some cases at the expense of their childrens’ health) is the way to square things up, then so be it, but that is clearly not a constructive solution. Patients are not allowed to give informed consent if they do not have insight.

  • Griflet

    quaker:

    Friend, I am sorry if I offended Thee. I see that I was much too personal in my comments. Had I reflected more before speaking I might have been clearer. Resentment would have been a better term than insult for what I was trying to describe. It changes the initiation of the behavior from you to the parent and is probably more accurate.

    I once got hit a few times by a man who thought I had insulted him when I thought I was asking about something. A motorcycle had just been stolen outside and I was trying to find out about it. The man who came in was trying to tell me something that seemed to me to have nothing to do with the situation. I persisted about the motorcycle, not listening (I never found out what he had tried to tell me). He thought I was accusing him of taking it.

    An OBG resident in an emergency room where I worked got hit over the head with a wine bottle trying to tell a man that the woman he had brought in with abdominal pain had PID and he that needed to be treated as well. The resident had tried to talk to him about it in front of his friends who were waiting around the outside door when he could have asked the man into a room with some privacy. This might not have helped, but he would not have attempted this approach with someone who appeared middle class and was white.

    The chief animal control officer in the mostly urban county where I used to live, hired only women officers because they were perceived as less threatening when investigating neglect and abuse than men were. They had a higher success rate and less confrontation requiring police back up. This had as much to do with how they were perceived as to how they approached people.

    Understanding how we got here is only a step, figuring what to do about it is more difficult. Being white and male is a double challenge. We often assume, without thinking that our agenda or knowledge is more important than others peoples, especially if they are less educated, female or non-white. Though we may be reluctant to admit it we often are much less likely to assume the same posture with other white men we perceive as be equal in socioeconomic stature.

    In white society physicians are generally recognized as having authority, respect and prestige, three things that make people more likely to accept or believe what they say. They can come to expect this response without thinking when they are working. Most black people know about the Tuskegee experiment, most white people don’t. Most black people, even secrete service agents, have had to wait in situations where white people don’t and when white people do have to wait they done even think about the possibility that it’s because they are white. Nnother provided several quotes from W.E.B. Bu Bois on the blog for the initial week of this discussion: “It is a peculiar sensation, this double-consciousness, this sense of always looking at one’s self through the eyes of others, of measuring one’s soul by the tape of a world that looks on in amused contempt and pity.�

    One of the guests or a caller in a subsequent broadcast referred to a study that black people think about their color/race almost daily or even many times per day; white people hardly ever think about it.

    JC suggested you get some of the others in your program to talk about their experiences in the situation. I hope you take him up on it.

    I’ve used a lot space talking about interpersonal aspects of race when I want to talk about changing institutions. We need to change from a curative model of medical care to a public health oriented one for everyone. We spend more and more on treating preventable diseases making basic medical care available to fewer and fewer. This approach will proportionately disadvantage non-white and poor populations. I hope that today’s discussion will make a start on to go about this.

  • Dear Open Source . . .

    I thank you for airing America’s dirty laundry. In August 2005, three reports discussing racial disparity in health care were released. Nonetheless, the myth lingered.

    People claimed, “The United States is a melting pot.� It is not. They said, “People are created and treated equally.� The truth is they are not. When we consider health care practices, we know this. Discrimination is prevalent.

    When the studies were first reported numerous people preferred to ignore the truth. Then there was Katrina. The facts surfaced. They were visible on our television screens. We read of them in our newspapers and heard them on the radio. A society that thought of itself as color-blind realized it was not.

    Many people of color were not and are not as the average American is; they were and are not living well. They are treated poorly. Numerous Black Americans are impoverished in this land of luxury. The medical services they receive barely and rarely allow them to survive.

    I invite you to read the thoughts of medical professionals as they discuss this topic. I ask you to travel to my treatise. Please share your comments on . . .

    COLOR BLIND SOCIETY? HEALTH CARE GAP CONCLUDES SOCIETY SEES COLORS ©

    http://be-think.typepad.com/bethink/2005/10/color_blind_soc.html

    Betsy L. Angert

    Be-Think.typepad.com

    http://be-think.typepad.com/

  • bloggeddown

    The driving force behind all of this – health care reform – must be motivated {sadly in this real world} by business interests. What I cannot understand is how American business can let the inefficiencies of the existing health care system continue – quite simply, it is KILLING their profitability. It is forcing the manufacturing base right out of this country.

    From the inappropriate use of emergency rooms for routine care of the urban poor, the incredible amount of and duplication of paperwork inherent in the physician practice and insurance systems, and the unequal mutli-tiered, multi-level of preventive care for the more wealthy vs the acute care for the poor are some of the reasons why the system is broken.

    What is needed is a single payer system – fully insured for all citizens at the National Level: one standardized form for patient care – one standardized system regardless of rural vs urban, black vs white neighborhoods.

    Get businesses out of medicine, get insurance companies out of medicine.

  • mandylanda

    Stephen Bezruchka – From the Womb to the Tomb – is incredibly informative regarding this issue.

  • Abby

    Chris said at the very end, “we still haven’t addressed the issue of universal health insurance.” That’s a subject that we really need a show on.

  • Griflet

    I agree with Abby that we should address the issue of universal/single payor medical insurance. This is probably necessary to solve racial inequalities in

    care but won’t resolve the problem without a lot of other things like education changing as well. For profit medical care would need to be limited and “non-profit” care better regulated. Additionally it would need to move from a primarily curative model to include significantly preventive one.

  • joel

    Check out how Dr. Sharon Lee does it in her clinic in Kansas City:

    http://www.humanmedia.org/program_familyhealthcare.php3

  • Griflet

    joel,

    Thanks for reminding me of Dr. Sharon Lee’s work. I had seen a piece on her clinic on TV (probably public) some time ago. I think its actually set up as her private practice so she has a lot of control over how things are done. A lot of physicians are heavily in debt when they finish, a program that erased the debt in exchange for working in such a program would be a great idea. I suspect that replicating this program would be dificult and that our government would be incapable of that. It’s a beautiful thing but might be dependent on its founder for insight and direction. I wonder how she sees the situations liberal quaker describes.

    I found some links to information on environmental health and the black community, especially post Katrina that others one this blog might find interesting. Robert Bullard (not the deep sea explorer) at Clark Atlanta Universitys’ Deep South Center for Environmental Justice has some of his op ed pieces posted there. There are links to these and articles by others on their web site:

    http://www.ejrc.cau.edu

    The testimony of Beverly Wright PhD to the House Sub-Committee on Environment and Hazards is one of the more interesting. I think Lee, Bullard and Wright would all be good guests to help us expand and deepen this discussion about racial disparities in health.

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