Features
Minority Health Care---Separate and Unequal
By Bruce E. Phillips
Nov 1, 2006, 17:36

Racial and ethnic disparities in U.S. health care are well documented. One of the most thoughtful and thorough examinations of health care disparities was chaired by Louis W. Sullivan, M.D., a former secretary of the U.S. Department of Health and Human Services. The Sullivan Commission concluded, in a report published in 2004, that the primary cause of the poor health care for minorities resulted from unequal representation of these minorities in the health care professions:

 “The lack of minority health professionals is compounding the nation’s persistent racial and ethnic health disparities. From cancer, heart disease, and HIV/AIDS to diabetes and mental health, African Americans, Hispanic Americans, and American Indians tend to receive less and lower quality care than whites, resulting in higher mortality rates.”

While African Americans, Hispanics, and Native Americans make up more than 25 percent of the U.S. population, they account for only nine percent of nurses, six percent of physicians, and five percent of dentists, according to the Sullivan Commission report.

Increasing the number of ethnic health care providers, however, will not in itself solve this complex, multifaceted problem. So what will? Science Spectrum recently interviewed several experts to discover why minorities continue to suffer from disparities in health care and, most importantly, to learn what can be done about it.

Self-inflicted Wounds

Many of the diseases that disproportionately harm minorities, such as diabetes and heart attacks, are made much worse by cultural habits and traditions. Obesity is an example. A National Health and Nutrition Examination Survey, published recently in the Journal of the American Medical Association found that nearly 40 percent of all non-Hispanic Black youth surveyed were obese. Not fat, not chubby---obese.

Obesity is the direct result of diets high in excess fat, carbohydrates, and salt. Lack of regular exercise is also cited as a contributing factor. Obesity, like health care itself, seems to be a class issue. Education, culture, and income appear to be the culprits. Wealthier Americans of all races tend to be healthier, more weight conscious, and insistent on better health care. And they get it.

Thomas A. LaVeist, Ph.D., is director of the Johns Hopkins University Center for Health Disparities Solutions. He is the author of Minority Populations and Health: An Introduction to Health Disparities in the United States, published by Jossey-Bass.

He says, “The evidence is overwhelming” that health care disparities do exist, explaining that “there are health care disparities across race and social status. ... There are disparities in access, utilization, and quality of care received.”
 
Determinants for these disparities involve a complex web of genetics, individual behavior, and socio-environmental factors.

“These disparities determine how long we live and how healthy our life is,” Dr. LaVeist emphasizes, offering a number of statistics to buttress his argument: Whites live an average of 5--7 years longer than Blacks. African Americans are more likely than whites to be victims of homicide and HIV/AIDS. Infant mortality is double for Blacks. “It’s been that way since statistics have been kept,” he says.

While the social environment is partly to blame for health disparities, economic policy is also a factor. Noting that health insurance is still largely employer based, not government based, and that Blacks suffer disproportionately from unemployment, Dr. LaVeist believes that serious changes to the health care delivery system itself are in order. He says, “Forty-six million Americans have no coverage, and there is a great difference between quality and scope of health coverage for those who have it.”

“Every other western society has a government-sponsored health care program, which provides exactly the same health care coverage to every citizen,” he emphasizes.

He isn’t convinced that simply increasing the number of minority health care providers will solve the problem. “There is no evidence to suggest that increasing minority health care providers will increase the quality of care.” However---and this is true for all ethnic groups---patients report more satisfaction when they are of the same culture as the provider.

No Easy Solutions

“There are no easy solutions,” says Dr. LaVeist. “The most promising solution is to focus on evidence-based quality improvements, where they standardize care as much as possible.”

He is not impressed by “racial medicine” theories, whereby drugs are targeted for people according to their race. “I am not convinced that there are genetic differences” that substantially affect medicine, he says, continuing, “Race has complicated and compromised science. … Race has the ability to make logical people not think logically. ... Minor genetic differences cannot begin to explain the disparities we see in health care, even if minor genetic differences do exist.”

“I think the solution to health disparities is to fix issues logically. Get politics and political correctness out of it,” he tells us.

Garth N. Graham, M.D., M.P.H., deputy assistant secretary for Minority Health, Office of Minority Health, Department of Health and Human Services, agrees that “diabetes, heart disease, and obesity all disproportionately impact minority communities.”

Infant mortality death rate is an indicator of the health of a population, Dr. Graham says, pointing out that the African-American death rate for infants is twice as high as that of white infants. It’s even worse for Native Americans, where the infant mortality rate tops that of whites by a full 48 percent.

He is most troubled by the high rate of HIV/AIDS among minorities and says, “Blacks have 38 percent of all AIDS-related deaths in the U.S., despite the fact that they are only 12 percent of the total population. ... In 2004, the rate of AIDS for Black women was 23 times higher than for white women, and 8 times higher for Black men than white men.”

Dr. Graham advocates a number of steps to improve health care for minorities. For one thing, it would help to have more diversity in the health care work force, because patients and providers with the same background work well together. What’s more, in his view, cultural competency does impact quality of care. This includes behavior as simple as respecting the values and customs of patients, as well as language proficiency to make it possible for provider and patient to communicate freely. 

To achieve parity, he says, it is important to provide the same standards of care for the same symptoms, regardless of race or class.

If increasing the size of the minority work force is important, how can this be achieved? Dr. Graham says his office is working with minority colleges and universities---including the HBCUs---as well as majority institutions to encourage students to get into the health field, but acknowledges that “We need to double our efforts and reach out to people. ... Minorities bring cultural sensitivity. We need health care professionals to be representative of our communities.”

He emphasizes the importance of creating public-private partnerships to reduce disparities. “Everybody needs to be aware of this problem,” he says. “It’s not just a racial or ethnic problem. It affects everyone. We need everybody involved, not just the public sector.”

<Subhed>Invisible People

Polly Olsen sees minority health care problems firsthand. As director of the University of Washington’s Native American Center of Excellence, she works to improve the lives of Native Americans. A member of the Yakima tribe, she grew up on Washington’s Yakima reservation and attended public schools before earning a college degree in cultural anthropology.

The role of centers of excellence, like the one Olsen oversees, is to encourage, recruit, and retain Native American students to be health care professionals and return to the tribal community.

She told Science Spectrum that the health care disparity among American Indians is very real. “Native medical problems are similar to those in other minority populations,” Olsen points out, citing obesity-related illnesses such as diabetes, arthritis, cardiovascular disease, cancer, and others.

She says that Native Americans tend to be left out of national studies and research, which further alienates this community from the larger health care community. There are a number of reasons for this, it turns out. For one thing, many Indians are unwilling to participate because they don’t want to be guinea pigs. They distrust the American research system in part because they doubt that the benefits will ever get back to them. Furthermore, the Native American population is small and, consequently, difficult for health care researchers to access. This issue of being invisible is especially true for urban Indians, she believes, because they blend into the dominant culture and are not easily identified as ethnics.

Lack of adequate health care funding is another problem for Native Americans. According to Olsen, the Indian Health Service (IHS) has the lowest payout per patient of any federal health program. The IHS receives approximately $1,000 per patient for a year of health care, she says, while veterans receive about $5,000. “Prisons get more per patient than the Indian Health Service,” she says.

This situation is made worse, in her opinion, by the fact that there are few Native Americans in the health care profession. Olsen says, “We need to educate more Indian health care professionals to return to tribes. ... Native people are more likely to comply and communicate with a doctor who is Native American.”

<Subhed>Do It Now

When the Sullivan Commission published its report in September 2004, it cited the shortage of minority health workers as a key factor in explaining the discrepancies that citizens of color experience in health care: “The ghosts of segregation continue to haunt the health professions. ... The nation’s projected upcoming medical school graduating classes for 2007 include only 2,197 Black, Hispanic, and Native Americans out of a total of more than 16,000 students. The picture in nursing and dentistry is similar.”

Identifying the problem is a necessary first step, of course, but it is not a solution. Change requires action, and the Commission, by recalling the words of Dr. Martin Luther King Jr., offered a time frame for action: “The time is always right to do what is right.”

The Sullivan Commission identifies several steps to improve minority health care.

Ÿ Increase diversity in the health professions.
Ÿ Increase the pipeline to health care professions by exploring new and nontraditional paths to these professions, such as improving K--12 education for minorities so they qualify for higher education in health care.
Ÿ Reduce dependence on loans for health care students and increase scholarships for minorities.
Ÿ Reduce the dependency on standardized testing for admission to schools of medicine, nursing, and dentistry.
Ÿ Enhance the role of two-year colleges in preparing students for careers in the health professions.
Ÿ And, finally, increase federal spending to support diversity health care programs.