Will you live to 100, 80, or a fraction of the average life expectancy? Factors such as race/ethnicity, socioeconomic status, gender, and access to quality healthcare, safe housing, and healthy food play a significant role in how long you live and how likely you are to develop certain conditions.
COVID-19 shone a klieg light on health disparities for everyone to see. The risk of becoming infected, suffering complications, being hospitalized and intubated, and dying from COVID-19 is disproportionately higher for Indigenous peoples, Black, and Latinx communities. These disparities are deeply rooted in the system racism of American medical history – past, present, and in the making – to which medical institutions, research, medical school curricula, and clinicians have all contributed. Narrowing the gap will take a collective effort and both a genuine acknowledgment and deep understanding of how the past continues to impact our nation’s health today and for future generations.
What are health disparities?
According to Healthy People 2030 a health disparity is “a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage.”
Health disparities result in negative differences in such factors as disease prevalence and complications, quality of care, treatment options, and health outcomes.
Healthy People 2030 notes that disparities adversely affect groups who have systematically experienced greater obstacles to health based on:
- Racial/ethnic group
- Religion
- Gender
- Age
- Socioeconomic status
- Mental health, cognitive, sensory, or physical disability
- Sexual orientation/gender identity
- Geographic location or other characteristics historically linked to discrimination or exclusion
Other factors which contribute to health disparities and inequitable health outcomes include:
- Systemic racism, sexism, and differential treatment based on sexual orientation, gender identity, and immigrant status
- Unconscious and conscious bias in the healthcare system – healthcare practitioners, professional schools of medicine, research, medical associations – and inadequate diversity in the healthcare workforce
- type of health insurance coverage (or lack thereof)
- lack of cultural sensitivity, humility, and competence
- poor practitioner communication skills
- language barriers and lack of interpreter services
- family history
- epigenetics
The availability, accessibility, and quality of treatment options may vary depending on where you live or who you are. You may face worse health outcomes if you belong to a historically underrepresented or marginalized group, are of low socioeconomic status, live in a rural area, or have a sexual orientation or gender identity other than heterosexual male or female, according to the National Institute on Minority Health and Health Disparities.
There are implicit (and explicit) biases too. For example, some healthcare practitioners treat African American patients differently than their white counterparts, perceiving them to be more likely to engage in unhealthy or risky behaviors, and are less likely to prescribe narcotics and pain medications for a Black patient.
Dayna Bowen Matthew puts it simply in the book Just Medicine: A Cure For Racial Inequality in American Healthcare, “What we politely call a ‘health disparity’ is killing people of color daily. It is causing people of color to live sicker and die quicker because of the color of their skin.”
Being a Doctor ≠ Protection
An African American doctor battling COVID-19 shared her experience at an Indiana hospital shortly before she died of the virus.
“All I know is that I am in intense pain,” Dr. Susan Moore said in a social media video. “[The doctor] made me feel like I was a drug addict, and he knew I was a physician.”
“I put forth and maintain, if I was white, I wouldn’t have to go t
h that,” she said. “This is how Black people get killed when you send them home, and they don’t know how to fight for themselves.” She was sent home. Then, later re-hospitalized at a different hospital, and died.
It speaks volumes to the disparities some patients experience when seeking treatment.
Medicine’s racist history
While Dr. Moore brought much-needed attention to disparities that happen every day in healthcare settings, it will take a long time to untangle the many layers of structural racism.
Transforming internal procedures and policies are a step forward. Still, racism is entrenched in medicine and society, including the American Medical Association (AMA), whose stated goal is to promote the betterment of public health.
The AMA has publicly acknowledged its role in the history of racism, especially against Black and female physicians.
Many consider Dr. Nathan Davis to have been the AMA’s founder. He explicitly excluded women and Black physicians from representation in the AMA’s House of Delegates. He also blocked the acceptance of an integrated group of physicians, despite efforts by other AMA physicians to support membership for this group of Black and white physicians.
“This historical fact defines Dr. Davis’ role in blocking integration and promoting and embedding racism in the AMA. Dr. Davis’ role was highly active, not passive, and his choice for a racist direction was pursued with energy and force,” wrote James L. Madara, MD, CEO and Executive Vice President.
This move gave rise to a white, male-dominated power structure. State and local medical societies also openly discriminated against Black physicians, withholding professional support and blocking advancement opportunities.
As a result of this 174-year history, AMA leaders acknowledge they contributed to a system that’s inequitable, has fewer Black physicians, and leads to disparate health outcomes for some patients. Time will tell the degree of commitment to real change and if the organization is ready to “walk the talk” in a meaningful and sustainable way.
The AMA is just one of many medical institutions whose policies and behavior manifest racism throughout the healthcare system, enabled biases, and contributed to the myriad health disparities we see in both medicine and medical training, as well as the diversity deficit seen in the medical workforce of today.
Other examples include:
The “Tuskegee Study of Untreated Syphilis in the Negro Male,” during which curative treatment with penicillin was withheld, leading to the completely preventable ravages of the disease.
Other examples include:
- The “Tuskegee Study of Untreated Syphilis in the Negro Male,” during which curative treatment with penicillin was withheld, leading to the completely preventable ravages of the disease.
- The Johns Hopkins case of Henrietta Lacks – an African American woman who suffered and died from aggressive cervical cancer at the age of 31. Her “HeLa” cells have served as a germ line for decades for the study of a variety of conditions and the advancement of medicine. Her cells were used without her consent, without the knowledge of her family, and without any privacy protections, even as it was being used extensively across the globe both for research and commercial purposes.
- A Cold War secret military experiment called Operation Big Buzz that tested the viability of deploying mosquitoes as a delivery system of disease warfare by dropping hundreds of thousands of mosquitoes on the Black neighborhood of Carver Village in Savannah, GA.
The result? Mistrust that’s rooted in historical, structural, and modern-day racism.
Health Disparities Example #1 – Pain Management
A study in the Proceedings of the National Academy of Sciences found pervasive racial bias in the pain assessment and treatment of Black patients. They’re less likely to be given narcotic pain medication, and, if they do receive it, the amount is lower.
It’s seen across all ages, including kids with appendicitis. A study of nearly a million children diagnosed with appendicitis found Black patients were less likely to get pain medication and less likely to get opioids for severe pain.
Why does this happen? There are many factors, including some clinicians who believe Black people feel less pain or a request for pain relief is “drug-seeking” behavior. This happens even in instances such as a leg fracture.
The ability to deliver optimal care demands the ongoing journey of increasing one’s cultural competency.
Health Disparities Example #2 – COVID-19 treatment and vaccination
Although African Americans with COVID-19 and cancer are more likely to be hospitalized and intubated, a study found they are half as likely to receive treatment with remdesivir, a medication found to shorten the time to recovery, reduce the likelihood of progression to severe lung disease, and lower mortality.
And now that potentially life-saving vaccinations are available, the disparity journey continues for those well-documented to be at greatest risk. Despite three vaccines with EUA clearance by the FDA and growing supplies, as of April 2021, Black communities are being vaccinated at half the rate of those who are white, and the news is even worse in the Latinx community. The often touted vaccine hesitancy, though real for some individuals, does not explain the magnitude of the dramatic differences seen to date. And hesitancy is not the same as refusal to be vaccinated, which is a stance currently held by a third of the population outside communities of color.
Racism as a public health crisis
Structural racism permeates all aspects of society, impacting the lives of millions, including those not yet even born due to the impact lifestyle/lived experience can have on epigenetic impacts from one generation to others.
During COVID-19, racism was declared a public health crisis by some communities. And many eyes were opened to what had been known for decades – an insidious infrastructure that has successfully subjugated certain groups since the U.S. was founded and has continued to do so to the present day.
The result? Redlining in housing, environmental injustice, disparities in education, job discrimination, voter suppression, lower socioeconomic status, and generations living with a low wealth status.
And then there are the headlines filled with stories of Black men and women being disproportionately and inequitably jailed, charged, and sentenced, and even murdered in the streets by law enforcement.
In the day-to-day reality of the novel coronavirus pandemic, systemic racism has meant Black and Hispanic/Latinx populations are often in low-wage, frontline worker positions deemed to be essential. Many find themselves in jobs which mean a high rate of potential exposure to COVID-19, often with inadequate PPE.
And for those in the Asian community, racial slurs, threats, injury, and deaths from hate crimes have skyrocketed over the past 15 months.
Racism also leads to situations in which social determinants of health play an outsized role in health outcomes. African Americans are more likely to live in poverty, to reside in more densely populated neighborhoods with limited access to healthy foods, parks, and quality medical care. Rashawn Ray of The Brookings Institution comments that “healthcare resources are criminally inadequate” in Black communities.
While COVID-19 is at the forefront right now, it’s just the latest kid on the health disparities block. Maternal mortality for African American women is 3 – 4 times greater than their white counterparts. This statistic holds regardless of the socioeconomic and educational status an African American pregnant woman may have attained.
Breast cancer rates are rising for African American women. And breast cancer in Black women is often more aggressive, less amenable to treatment, and diagnosed at a later stage. For Black men, prostate cancer develops at a younger age and is more aggressive.
According to U.S. Vital Statistics, African Americans also have higher rates of:
- cardiovascular disease (hypertension, congestive heart failure, stroke, coronary artery disease)
- chronic kidney disease
- diabetes
- obesity
- certain cancers
- HIV/AIDS
- Preterm delivery and infant mortality
Recognizing racism as a public health crisis means acknowledging the impact – a shorter life and reduced quality of life as well as the need for more customized preventive care guidelines. For example, starting colon cancer screening at a younger age and pursuing prostate cancer screening rather than waiting for the development of symptoms.
The United States Preventive Services Task Force (USPSTF) is the body which makes preventive care recommendations and guidelines upon which the public and the medical community depend. USPSTF has been found to inadequately address health disparities in several instances. Most recently, in the area of lung cancer screening.
“There’s never been a time, not a single year, where the [U.S.] population of African descent hasn’t been sicker or died younger than Whites,” said Mary T. Bassett, a physician and director of the FXB Center for Health and Human Rights at Harvard University in a Washington Post article.
The disparities are so significant that a Black person may live a decade less than a white person in some cases.
Finding a path forward from COVID-19
We’re faced with a situation as a country where we have to move urgently to substantially, effectively, and sustainably learn to live in a world that will continue to include COVID-19.
Eradicating health disparities is the right and moral thing to do. Additionally, health disparities often reveal systemic issues that impact not only certain segments of the population but the majority of patients regardless of the group to which they belong. Health disparities negatively impact all of us. And, therefore, addressing them benefits us all.
And if those reason are not sufficient to make achieving health equity a national priority, there’s a business case too. There are financial implications for everyone.
A 2020 study in Texas estimated the cost of health disparities in the billions and growing. That’s billions for a single state alone.
The National Quality Forum published a roadmap for promoting health equity and eliminating disparities, through the four I’s:
- Identify and prioritize reducing health disparities
- Implement evidence-based interventions
- Invest in the development and use of health equity performance measures
- Incentivize the reduction of health disparities and achievement of health equity
The intersection of a pandemic and racial injustice demands every healthcare institution take action.
COVID-19 underscores the multitude of reasons Indigenous peoples, Black, and Latinx communities are facing a disproportionate risk of getting the virus and dying. It’s a long-standing, complicated, systemic problem that negatively impacts every aspect of life.
Addressing health disparities requires a holistic approach that recognizes how intertwined they are in all facets of society and institutions.
It’s been a goal for decades. What will you do to reverse this trend?
