Medicine works to fix its racial and ethnic inequities

We can all agree that health and wellness should be equal opportunity goals for all Americans, and your skin color shouldn’t matter. But it does.

The health numbers for Blacks, Latinos and Asian Americans are so different from white Americans, and have persisted for so long, that we are finally doing something about it.

The reforms should help the health care of everyone, as we learn the ways to plug the racial and ethnic health gaps.

Meantime the patterns are striking:

Black Americans, as the Associated Press found in a year-long investigation, “have higher rates of infant and maternal mortality, higher incidence of asthma during childhood, more difficulty treating mental illness as teens, and higher rates of high blood pressure, Alzheimer’s disease, and other illness as adults.”

Diabetes and obesity plague Latinos in this country, adding to their struggles with poverty and access to the U.S. medical system.

As federal medical scientists have reported: “Asian Americans have the highest incidence and mortality rates of liver and stomach cancers — the most preventable cancer — largely due to high prevalence of related infections such as hepatitis B. In addition, Asian Americans have the lowest cancer screening rates and are typically diagnosed at a later stage compared to other racial and ethnic groups.”

It took the pandemic to bring long simmering racial disparity issues to a boil.

Confronted with disproportionate Covid-19 deaths and debilitations of minority patients in a pandemic that killed more than 1 million Americans, doctors, hospitals, medical schools, and medical scientists have undertaken a painful but necessary review to treat patients more equally and fairly.

Big changes are still needed. But already some surprises have emerged, and important lessons have been learned, providing patients and medical providers with valuable takeaways for improved medical care for us all.

The issue of race can be so fraught that some advocates say the nation best presses toward a more ideal world by ignoring it altogether. We’re more equal this way, they contend.

Rigorous research provides evidence to the contrary, finding that there are measurable differences among us and our health outcomes based on race. People are individual, different, and their race can be a major factor in population health and medical care. Startling proof of this is building in studies scrutinizing a fundamental, common-sense concern, especially for black patients: the importance of black doctors.

The presence of just one black doctor within a U.S. county led to increased longevity and lower mortality among all blacks living there, according to Stat, a science and medical news site, reporting on a study published in the medical journal JAMA Network Open. As Stat said of the examination of health and other data from 1,600 U.S. counties:

“The study … is the first to link a higher prevalence of black doctors to longer life expectancy and lower mortality in black populations. Other studies have shown that when black patients are treated by black doctors, they are more satisfied with their health care, more likely to have received the preventive care they needed in the past year, and are more likely to agree to recommended preventive care such as blood tests and flu shots. But none of that research has shown an impact on black life expectancy.

“The new study found that black residents in counties with more black physicians — whether or not they actually see those doctors — had lower mortality from all causes and showed that these counties had lower disparities in mortality rates between black and white residents. The finding of longer life expectancy persisted even in counties with a single black physician. ‘That a single black physician in a county can have an impact on an entire population’s mortality, it’s stunningly overwhelming,’ said Monica Peek, a primary care physician and health equity researcher at UChicago Medicine who wrote an editorial accompanying the new study. ‘It validates what people in health equity have been saying about all the ways black physicians are important ….’”

For black and brown patients, though, the potential benefits of having doctors that look like them runs into blunt reality: the dearth of black (and Latino) MDs, whether in vital primary care practices or as medical specialists. As the AP reported, “Black Americans represent 13% of the U.S. population, yet just 6% of U.S. physicians are black.” (Latinos make up 20% of the U.S. population but just 7% of U.S. doctors.)

Further, the U.S. Supreme Court — siding with affirmative action foes and asserting that “race blind” admissions are the fair way for colleges and universities to go — has spiked concerns that the “path into medicine may become much harder for students of color.” Medical educators and other experts already are racing to determine how they can ensure that the country has a robust number of black and Latino doctors.

They are, as a group, poorer than most, often lagging in education, and less likely to have access to medical care. They suffer outsized harms from diabetes, obesity, high blood pressure, and heart disease. Their diet, high in carbohydrates, calories, and excess sugar, raises concern among many health experts.

Yet on average, Latinos or Hispanics live a few years longer than their white counterparts. What gives?

This “Hispanic Paradox,” so named in 1986 by University of Texas researchers Kyriakos Markides and Jeannine Coreil, has perplexed medical researchers for decades. Stat, the science and medical news site, says contemporary studies are adding nuance to the issue:

“They’re finding that for Hispanics, living longer does not necessarily mean living healthier, and that lumping together people from places as varied as Brazil, Mexico, and Puerto Rico conceals important health risks for these individual populations, which may as a result go unnoticed by many American physicians. They’re also finding that healthy Hispanics who immigrate to the U.S. tend to get sicker the longer they stay — raising deeper questions about why our wealthy nation, which spends more than $4 trillion on health care, is far sicker than it should be. ‘Part of the story about the Hispanic Paradox,’ said Kyriakos S. Markides, a professor of aging at the University of Texas Medical Branch in Galveston, ‘is that the non-Hispanic white population is not doing as well as it should.’”

In the past, researchers have scrambled to explain Latino longevity, arguing unconvincingly that this occurred because the healthiest Hispanics returned to their homelands (nope), or that legumes (beans) in their diet offered health advantages (nope), or that the overall youthfulness of this population mattered (nope).

Researchers lately have tried to better understand Latino longevity, partly by diving deeper into the group and seeing its complexity — that is, that the Spanish-speaking peoples in this country come from an array of other nations and have distinct cultures [see below].

They share commonalities that studies suggest could play important roles in keeping humans healthier: Many Hispanics, researchers say, are spiritual and give certain powers to women and the individual, even in male-dominated, top-down societies. Latinos and those from Asian nations also are rooted in collective cultures in which communities support members in thick and thin, with extended families supporting those who are sick, debilitated, and old, Stat reported.

Americans of Vietnamese ancestry report in surveys that their health is fair or poor more than twice as often as non-Hispanic whites and Asian Americans overall. Those of Japanese ancestry, researchers at UCLA and Brown University have found, have a higher proportion of people who are obese or overweight than non-Hispanic whites and Asians overall. Japanese and Koreans report higher diabetes rates than non-Hispanic whites and Asians overall. Americans of Filipino descent appear to be in the worst health of all Asian subgroups. They have a greater prevalence of high blood pressure, asthma, heart disease, and delayed medication usage compared to Asians overall. They — along with Native Hawaiian and Pacific Islander people — suffered disproportionate deaths and debilitation during the coronavirus pandemic.

Until fairly recently, doctors, hospitals, policy makers, politicians, and other key players in the U.S. medical world might not have known vital health information like this.

That’s partly because a concerted campaign by U.S. activists of Asian descent successfully convinced many in this country of the existence and importance of a group called Asian Americans. These people are part of a rising, potentially politically powerful, accomplished, and increasingly affluent group living and working from coast to coast.

The descriptive term made sense, advocates say, dating to the 1970s and the efforts to win needed attention and clout for small, disparate groups of people tracing their roots to dozens of Asian nations. The description provided a crucial sense of identity, emphasizing “American-ness” and providing in unity a clout that had eluded people with a long history of harsh, unacceptable discrimination. This included exclusionary immigration policies, the unconstitutional incarceration of tens of thousands of citizens during wartime, and killings, beatings, and economic privation.

But over time, this country has made some progress. So, is being “Asian American” still a coherent idea when it encompasses new immigrant groups like the Burmese (annual median income $36,000) and Indians ($100,000+)? Do battles for more equitable treatment by Ivy League universities by Asian Americans with multiple generations in this country (such as those of Chinese and Japanese descent) resonate with impoverished newcomers from Cambodia, Nepal, and Bhutan?

Recent outbreaks of thousands of anti-Asian hate incidents argue — loudly — that Asian Americans (or AAs) need to retain the broad description of themselves to advance their cause.

The AA identification, as with terms like Latino and Hispanic (describing people rooted in other huge geographical areas) retains its value. Advocates say that establishment medicine also must work harder for “disaggregated data,” information on smaller subgroups that provides invaluable insight on their medical needs and treatment.

This information can be tougher and more time-consuming to develop and analyze — and for private and government funders to want to support.

But as Ninez A. Ponce, PhD, MPP, and director of the UCLA Center for Health Policy Research, has argued about sound medical policy making, based on hard data and factual evidence:

“We know that without data equity, we will not achieve health equity. But we also recognize that health inequity is rooted in systemic injustice, and we will work together to dismantle these barriers and achieve health justice. Health equity is not a destination, but an enduring process. “

As doctors, hospitals, and medical scientists delve into the national disgrace of Black mothers suffering disproportionate death and disease rates, a common theme keeps sounding. Why do so many Black women, no matter their economic or social standing, suffer so much during pregnancy and while raising their babies?

Their doctors fail to listen to them and take their medical concerns seriously. That’s a blunt truth the research is exposing.

Physician “gaslighting” is an unacceptable horror for women patients, in general, but it is lethal and debilitating for black women during pregnancy and after delivering, one of the most challenging parts of their lives, according to news media reports. Here is what the New York Times reported:

“Research suggests that diagnostic errors occur in up to 1 out of every 7 encounters between a doctor and patient, and that most of these mistakes are driven by the physician’s lack of knowledge. Women are more likely to be misdiagnosed than men in a variety of situations. Patients who have felt that their symptoms were inappropriately dismissed as minor or primarily psychological by doctors are using the term ‘medical gaslighting’ to describe their experiences and sharing their stories on sites like Instagram. The term derives from a play called Gaslight about a husband’s attempt to drive his wife insane. And many patients, particularly women and people of color, describe the search for accurate diagnosis and treatment as maddening. ‘We know that women, and especially women of color, are often diagnosed and treated differently by doctors than men are, even when they have the same health conditions,’ said Karen Lutfey Spencer, a researcher who studies medical decision-making at the University of Colorado, Denver.”

This newsletter has devoted an issue to this topic. We reported on data on U.S. care  for the pregnant and their newborns that is nothing less than a national embarrassment:

Our spiking U.S. maternal mortality and morbidity rates put this country in the same neighborhood as Afghanistan, Lesotho, and Swaziland. Black women are more than three times as likely as white women to die from pregnancy-related causes, while American Indian/Alaska Native are more than twice as likely. These disparities persist regardless of income, education, geography, and other socioeconomic factors.

The crisis harms infants, too, the New York Times reported:

“The number of American babies who died before their first birthdays rose last year, significantly increasing the nation’s infant mortality rate for the first time in two decades, according to provisional figures released … by the National Center for Health Statistics. The spike is a somber manifestation of the state of maternal and child health in the United States. Infant and maternal mortality, inextricably linked, are widely considered to be markers of a society’s overall health, and America’s rates are higher than those in other industrialized countries. The rates are particularly poor among black and Native American mothers, who are roughly three times as likely to die during and after pregnancy, compared with white and Hispanic mothers. Their infants face up to double the risk of dying, compared with white and Hispanic babies.”

This year, ProPublica, a Pulitzer Prize-winning investigative site, dug into problems black patients experience with stillbirths, reporting:

“Black women overall are more than twice as likely as white women to have a stillbirth, according to 2020 CDC data, the most recent available. In some states, including South Carolina, Kansas, and Tennessee, they are around three times as likely to deliver a stillborn baby. In Arkansas and Mississippi, the stillbirth rate for black women in 2020 topped 15 per 1,000 live births and fetal deaths; it was more than 11 in New Jersey and New York. The national stillbirth rate for black women was 10.3 and for white women 4.7. But drawing focus to black stillbirths is a challenge in a country where stillbirths, in general, have been understudied, underfunded, and received little public attention. In addition, the community of stillbirth researchers and advocates remains relatively small and overwhelmingly white.”

The New York Times suggested in its report on women and gaslighting that patients should consider bringing along a friend or companion to join them in doctors’ offices for appointments, taking notes and helping in other ways. And doctors can take steps to remedy some of the issues the newspaper reported, quoting the University of Colorado’s Dr. Spencer.

It’s hard to know how to begin to address these systemic problems, experts said, but scientists argue that at the very least, there needs to be more research on women’s health conditions. Doctors should also be given more time with their patients, and see fewer patients overall, Dr. Spencer suggested.

As the Times reported: “Research has shown that when people are juggling many cognitive tasks, they are more likely to make biased decisions. One study found, for instance, that male doctors were less likely to prescribe pain medications to black patients with lower back pain when the doctors were under stress. Physicians are often working under difficult conditions that ‘make it easy to make mistakes and oversights,’ Spencer said. ‘It’s like a gauntlet of problematic systems and processes that invite bias.’ Researchers have also called for more training in medical school about unconscious bias and racism in health care. In 2019, California passed a law requiring hospitals to implement implicit bias programs for all health care providers who provide perinatal care.”