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Subtle Racism In Medicine, Minorities Get Inferior Care, Even If Insured, Study Finds


Subtle Racism In Medicine

March 22, 2002
Copyright © 2002
THE NEW YORK TIMES. All Rights Reserved.

It has long been known that blacks, Hispanics and other minorities receive lower-quality health care than whites do, a disparity generally attributed to lower incomes, inadequate insurance coverage and lack of doctors in minority areas. These socioeconomic causes are real, but a disturbing new study by the Institute of Medicine has concluded that even when members of minority groups have the same incomes, insurance coverage and medical conditions as whites, they receive notably poorer care. Biases, prejudices and negative racial stereotypes, the panel concludes, may be misleading doctors and other health professionals.

The institute's 562-page report, which was requested by Congress, reviewed more than 100 studies that documented a wide range of disparities in medical care. Members of minorities were found less likely than whites to be given appropriate cardiac medicines or undergo coronary bypass surgery. They are less likely to receive kidney dialysis or kidney transplants or the best diagnostic tests and treatments for cancer. They are also less apt to receive the most sophisticated treatments for H.I.V., which can forestall the onset of AIDS.

All these lapses, the panel believes, contribute to higher death rates and lower survival rates among minorities compared with whites suffering from illnesses of comparable severity. At the same time that they are denied advanced treatment, members of minorities are more likely to receive less desirable treatments, such as amputation of the lower limbs for diabetes, that impair their quality of life.

The panel proposes a number of solutions, including increasing the number of minority doctors, improving insurance coverage to eliminate inequities, and relying on "evidence-based guidelines" to determine what care is given. But to the extent that doctors are shaping their treatments based on subconscious biases or false stereotypes about how blacks or Hispanics will respond to their ailments or their treatments, the only lasting cure will be greater awareness and education for the medical profession, as the panel recommends. Unconscious racism is every bit as damaging as the more overt forms of bigotry.

March 21, 2002


Minorities Get Inferior Care, Even If Insured, Study Finds


WASHINGTON, March 20 – Racial and ethnic minorities in the United States receive lower quality health care than whites, even when their insurance and income are the same, say a panel of scientific experts who termed their study a wake-up call to the nation's doctors.

The study, made public today by the Institute of Medicine, an independent research institution that advises Congress, is the first comprehensive look at racial disparities in health care among people who have health insurance.

While the so-called race gap in medicine has been well-documented, previous research has attributed much of the problem to lack of access to care. The panel cited subtle racial prejudice and differences in the quality of health plans as possible reasons why even insured members of minorities get worse care.

"The differences are pervasive," said Martha N. Hill, director of the Center for Nursing Research at Johns Hopkins University School of Nursing, and the co-vice chairwoman of the panel. "It cuts across all conditions of health and across the entire country, and we think this is a very serious moral issue."

Saying they were deeply troubled by the findings, the authors made recommendations that included additional research to understand how bias affects care, efforts to increase the number of minority doctors, and the use of interpreters to ease communication between physicians and patients who do not speak English.

The report, which reviewed more than 100 studies conducted over the last decade, concluded that the disparities contribute to higher death rates among minorities from cancer, heart disease, diabetes and H.I.V. infection.

It found that members of minorities were less likely to be given appropriate medications for heart disease, or to undergo bypass surgery, and are less likely to receive kidney dialysis or transplants than whites. They are also less likely to receive the most sophisticated treatments for infection with H.I.V., which could delay the onset of AIDS.

But members of minorities are more likely to receive certain less desirable procedures. The committee cited a study of Medicare beneficiaries, for instance, that found blacks were 3.6 times as likely as whites to have their lower limbs amputated as a result of diabetes.

"Some of us on the committee were surprised and shocked at the extent of the evidence," said the chairman of the panel, Dr. Alan R. Nelson, a former president of the American Medical Association. He added, "The evidence is overwhelming."

But Claude Allen, the deputy secretary for health and human services, said the findings did not surprise federal health officials. Mr. Allen said today that the Bush administration was continuing an initiative begun under President Bill Clinton to erase disparities in medical care.

"We believe that education is the key, both education for providers to be aware of the subjectivity of their decisions and education for patients, to allow them to take control of their health care decision making," he said.

The authors of the study offered multiple explanations for the disparities, among them quality of insurance. Members of minorities are more likely than whites to be enrolled in lower-end insurance plans that impose stricter limits on medical services, and that require doctors to see more patients, spending less time with each.

Yet the study found that differences persist even when minority and white patients have the same insurance, in part because minority patients are less likely than whites to have a long-lasting relationship with a primary care physician.

Racial bias, albeit subconscious, may also be at work, the study found. While the panel said most health providers were well-intentioned, it cited "indirect evidence" that doctors' decisions were influenced by their perceptions of race.

As an example, the authors cited a study of major medical centers in New York State that found African-Americans were 37 percent less likely to undergo angioplasty and other heart procedures, including bypass surgery, than whites. In 90 percent of the cases in which the patient did not get the surgery, the doctor had not recommended it.

In interviews with the doctors, the researchers found "classic negative racial stereotypes," the report said, such as assumptions that black patients would be less likely to participate in follow-up care.

"This is a timely and powerful report," said Dr. Lucille C. Perez, president of the National Medical Association, which represents black doctors. "It validates what the N.M.A. has been saying for so long – that racism is a major culprit in the mix of health disparities, and has had a devastating impact on African-Americans."

A spokeswoman for the American Medical Association, the nation's largest organization representing doctors, declined to comment on the findings, saying its officials had not seen the study. In a policy statement adopted in 1998, the medical association "encourages physicians to examine their own practices to ensure that inappropriate considerations do not affect their clinical judgment."

Although the medical literature is most complete on disparities between African-Americans and whites, the report found the disparities also extended to Hispanics.

Part of the problem, the report said, may be a lack of minority doctors. Minorities, including African-Americans, Asian-Americans, Hispanics and American Indians, account for just 9 percent of the nation's doctors.

David R. Williams, a professor of sociology at the University of Michigan who served on the panel, called the report "a wake-up call" for doctors and patients.

"We have a health system that is the pride of the world," Professor Williams said. "But this report demonstrates that the playing field clearly is not level."

Report Says Minorities Get Lower-Quality Health Care

Moral Implications of Widespread Pattern Noted

By Ceci Connolly

Washington Post Staff Writer

© 2002 The Washington Post Company

March 21, 2002; Page A02

Minorities in America -- even those with private health insurance -- receive lower-quality care than that given to whites, a pattern so widespread and severe that it contributes to higher death rates and shorter lifespans, a major report released yesterday says.

Although it was not possible to quantify the inequities, researchers identified language barriers, inadequate insurance coverage, bias among doctors and nurses, and a woeful lack of minority physicians as reasons why nonwhite patients received fewer tests and inferior treatment.

"This is a pervasive problem with moral and ethical implications for our society," said Martha Hill, a professor at Johns Hopkins University School of Nursing and vice chairman of the Institute of Medicine committee that prepared the report.

The problem of access to medical care among minorities is well documented, but the 562-page report is the most exhaustive analysis of the disparities in treatment and health outcomes. The report, requested by Congress, shines a harsh light on the effects of patient stereotyping and of an expensive health system that often forces patients to ration their own care.

"We have a health care system that is the pride of the world, but this report documents that the playing field is not even," said David Williams, a sociology professor at the University of Michigan who described the study as "a wake-up call for every health care professional."

A nonwhite patient in the United States today is far more likely to be treated by a white doctor who earns less, received less training and does not have a clear understanding of the patient's native language or cultural heritage, according to the report. Most remarkably, over the past three decades, the share of black physicians in the country rose from 3.5 percent to 3.9 percent.

The biggest discrepancies -- and the most devastating health consequences -- came in the areas of cardiovascular disease, HIV/AIDS, cancer and diabetes. African Americans, Asian Americans, Hispanics and Native Americans were less likely to receive sophisticated treatments such as angioplasty, bypass surgery, kidney transplantation or a combination drug therapy known as the "AIDS cocktail."

One study of 13,000 New Jersey heart patients found that far fewer African American patients received catheterization to clear the arteries, despite exhibiting the same symptoms. Another study involving 13,600 nursing home residents found that blacks "had a 63 percent greater probability of being untreated for pain relative to whites."

"Significantly, these differences are associated with greater mortality among African-American patients," the researchers note. "By contrast [minorities] are more likely to receive certain less-desirable procedures, such as lower limb amputations for diabetes."

Bias in medicine appears to parallel other societal stereotypes, said Alan Nelson, chairman of the committee. Medical schools often teach that some minorities complain more about pain or do not follow drug regimens; many doctors and nurses are unaware of cultural beliefs that can affect health, researchers said.

"Physicians and other health care providers are more comfortable interacting with people like themselves -- highly educated, articulate individuals," said committee member Risa Lavizzo-Mourey, senior vice president of the Robert Wood Johnson Foundation. "Providers go into health care professions with good intentions, yet the evidence does suggest there is unequal treatment."

A small number of minority patients refused tests or treatment, but those attitudes were "unlikely to be major sources of health care disparities," the report says. It was much more likely that doctors did not present the treatment options clearly to nonwhites or that minorities had to make medical choices based on cost.

The panel of experts offers a battery of recommendations, though many are nonspecific. The report calls for increased awareness, more interpreters, more minority physicians, better data and more money for the Office of Civil Rights, which enforces equity laws.

Black physicians and lawmakers hailed the report as long overdue, though some criticized the Bush administration for failing to put enough money into minority health programs. "This isn't only about health disparities," said Ivan Walks, director of the D.C. Department of Health. "It's a story about a missed opportunity to really spend resources differently."

Del. Donna M. Christian-Christensen (D-U.S. Virgin Islands), chairman of the Congressional Black Caucus, said the government's minority HIV/AIDS initiative and medical education programs that would help draw more minorities into the profession are underfunded in the proposed fiscal 2003 budget.

Today, Pfizer Health Solutions and the Washington Business Group of Health will announce a two-year project aimed at improving minority health through better information and screening, said Judith Campbell who is overseeing the effort for Pfizer. Offices are a logical place to reach minorities, she said, noting that, "by 2008, 41 percent of our workforce will be nonwhite."

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