Addressing Historical Health Inequities
Today, I received an email from an organization, requesting me to make arrangements for “free” Public Service Announcements on a Black Talk Radio station, to publicize an upcoming Health Conference.
Normally, this would not be a problem, since the state of Black health is a truly dismal picture, and any effort to address the inequities is a welcomed one.
However, the troubling part of this is that the request came from an organization that, even though they are non-profit, spends millions each year for the same Conference to be held in various cities around the country.
Granted, it’s a noble cause, and it is designed to overcome barriers, which traditionally contribute to the disparities in health, which negatively impact African Americans. But, the truth is, as my friend Rubin says, “ We still ain’t got our therapy”.
As Brent Staples states, in his New York Times article, “Historians tend to focus on mob violence and lynching when they write about the racial atrocities of the Jim Crow South. But, not all killings were carried out by men in white sheets armed with guns and nooses. Indeed, it’s obvious when you think about it that many more African-Americans died as a result of racist medical treatment in the South than at the hands of all the lynch mobs, bombers, and night riders combined.”
He goes on to talk about how Black physicians, who had formed the National Medical Association, fought against these horrors and urged the AMA to do the same. But the AMA remained shamefully mute at crucial junctures in the struggle for medical fairness.
It failed, for example, to fight against the Hill-Burton Act, the federal law that allowed the states to use federal funds in the construction of hospitals that would be segregated by race. It remained silent during the debates on the Civil Rights Act of 1964.
It also pioneered the “states’ rights” approach, allowing state and county chapters to keep out black physicians when and where they chose to. The same doctors who controlled membership in the AMA chapters prevented black doctors from getting hospital privileges and specialty training.
It would be 1968 before The AMA House of Delegates threatened to expel from the Association any state medical society that discriminates on the basis of race, even though Dr. James McCune Smith, the first African American finished a medical school in 1837.
From the viewpoint of patients, the infamous Tuskegee “Experiment”, and other horrific acts have compiled a vast mental history in the minds and consciousness of Blacks, and continue on until today, manifesting in chronic distrust, and suspicion.
Yet, even after President Clinton, in 1997, offered a formal apology to the five, aged survivors of the “Experiment”, little has been done to address the dark medical experience of African Americans in the US medical system.
As a result, Race still matters…
Race and ethnicity influence a patient’s chance of receiving many specific procedures and treatments. Of nine hospital procedures investigated in one study, five were significantly less common among African American patients than among white patients; three of those five were also less common among Hispanics, and two were less common among Asian Americans. Countless studies have revealed additional disparities in patient care for various conditions and care settings including:
• Heart disease. African Americans are 13 percent less likely to undergo coronary angioplasty and one-third less likely to undergo bypass surgery than are whites.
• Asthma. Among preschool children hospitalized for asthma, only 7 percent of black and 2 percent of Hispanic children, compared with 21 percent of white children, are prescribed routine medications to prevent future asthma-related hospitalizations.
• Breast cancer. The length of time between an abnormal screening mammogram and the follow up diagnostic test to determine whether a woman has breast cancer is more than twice as long in Asian American, black, and Hispanic women as in white women.
• Human immunodeficiency virus (HIV) infection. African Americans with HIV infection are less likely to be on antiretroviral therapy, less likely to receive prophylaxis for Pneumocystis pneumonia, and less likely to be receiving protease inhibitors than other persons with HIV. An HIV infection data coordinating center, now under development, will allow researchers to compare contemporary data on HIV care to examine whether disparities in care among groups are being addressed and to identify any new patterns in treatment that arise.
• Nursing home care. Asian American, Hispanic, and African American residents of nursing homes are all far less likely than white residents to have sensory and communication aids, such as glasses and hearing aids. A new study of nursing home care is developing measures of disparities in this care setting and their relationship to quality of care.
An area of Medicine that, in my opinion, reflects this void the greatest is Clinical Trials Research. Black Americans tend to be under-represented in clinical trials, which are responsible for most advances in medicine.
Project IMPACT (Increase Minority Participation and Awareness in Clinical Trials), a recent study, found that minorities are 200 percent more likely to perceive harm coming from participating in research.
Among the study’s other findings:
• 24 percent of black Americans reported that their doctors would not fully explain research participation to them, versus 13 percent of whites.
• 72 percent of black Americans said doctors would use them as guinea pigs without their consent, versus 49 percent of whites.
• 35 percent of black Americans said doctors would ask them to participate in research even if it could harm them, versus only 16 percent of whites.
• 8 percent of black Americans more often believed they could less freely ask questions of doctors, compared with 2 percent of whites.
• 58 percent of black Americans said doctors had previously experimented on them without consent, compared with 25 percent of whites.
Among the study’s other findings: When the element of distrust was removed from the equation, the proportions of blacks and whites willing to enroll equalized to that of whites.
Designing health initiatives that acknowledge and are based in the unique historical and cultural context of racial and ethnic minority communities in the United States is critical to removing this “unhealthy” barrier.
An important step in undoing health disparities is to change the pattern of relationships between people and the organizations and social structures affecting their health. Equipped with key information, both individuals and communities can change their relationships with health care systems, community organizations, schools, businesses and other economic institutions, and policy makers. This process of empowerment engages individuals and communities in understanding and exercising control over their future health.
Critical for the long-term success of initiatives designed to eliminate health disparities is the establishment of principles ensuring that an initiative will invest in a community and recognize and value community members with expertise that does not come from formal training.
Eliminating health disparities invokes a sense of power over one’s destiny and gives hope that something can be done to ensure a healthier and vital future. Therefore, when planning community interventions to eliminate health disparities, it is essential to build a sense of hope in the community that the future will be brighter than the past. By sharing and using these principles, we will become a nation that will help people-regardless of race or ethnicity-obtain and maintain optimal health.
This includes, acknowledging that it is not acceptable to spend thousands of dollars on catering; audio/visual equipment; staff salaries; travel; honorariums; etc., and then ask a financially struggling radio station to provide free advertisement to get listeners to come out to an event: even though it is in their best interest to do so.
As Rubin would say, “ We still ain’t got our therapy”…