A New Study on Racial and Ethnic Disparities in Medical Care
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RAY SUAREZ: Now, racial and ethnic disparities in health care. That subject is the theme of the latest issue of the journal Health Affairs. It’s also the focus of a conference here in Washington sponsored by the Robert Wood Johnson Foundation, which underwrites the NewsHour’s health unit.
Among the findings in Health Affairs: There’s a significant gap in mortality rates between black Americans and white Americans, a gap that accounts for 80,000-plus excess deaths annually among African-Americans.
For more on the disparities and what can be done it, I’m joined by Dr. Adewale Troutman. He’s a co-author of that study and director of the Louisville Metro Health Department. He also serves on the faculty of the University of Louisville School of Public Health. And welcome.
What did you find in your overall assessments of health among different Americans?
DR. ADEWALE TROUTMAN: Well, the first thing is that we did find that there’s been an increase in improvement in the health of all Americans if you look across the board over the past 40 years. But the gap in mortality rates between blacks and whites in particular, which is the group that we studied, remain constant.
In other words, as everyone’s health has improved, but the gap between those two groups has not. And, in fact, in some instances, it’s gotten worse. It’s gotten worse for black babies. It’s gotten worse for African- American men. It’s improved slightly for African-American women, but then has leveled off.
So we’re seeing a continuation of the excess death gap that has been in existence for at least 100 years and probably more based upon the availability of good literature and statistics going back several centuries.
RAY SUAREZ: Well, you note that everybody’s health has gotten better.
DR. ADEWALE TROUTMAN: Correct.
RAY SUAREZ: But black Americans have had a significant decrease in their poverty rate, a significant increase in the amount of education, a very large number have moved into the middle class, and yet this tremendous gap persists. Why?
DR. ADEWALE TROUTMAN: Well, I think it has a lot to do with several factors, including what has recently been discovered as an issue of discrimination, potential racism, stereotyping and bias within the health care delivery system as defined by the Institute of Medicine report published in 2002.
In other words, if you take… if you balance out for everything else… not income, by the way, because income is another factor that has remained constant — the gap in income, the gap in asset wealth, specifically, has remained constant over the years, as well. And there was a specific connection between asset wealth and health outcomes.
And that may be a part of the answer as to why the black-white mortality gap has continued over these many years. But that particular aspect of healthcare that says that when you go into a provider, whether it’s a hospital or an individual practitioner, and you happen to look a certain way– and there is a belief based upon the IOM report that there is provider attitude, whether it’s conscious or unconscious and/or whether it’s institutionalized racism that, in fact, dictates the kind of care that an individual is going to get– there’s good evidence to shows that there is, in fact, poorer health outcomes based upon the kinds of referrals that are given to individuals.
And it’s believed that there’s an association with those referrals and provider attitudes and potentially bias and stereotyping and discrimination in the health care delivery system.
RAY SUAREZ: Give me an example. If someone shows up in a hospital and they’re both being treated for similar maladies, what’s going to be different about the kind of care that one person gets as opposed to another?
DR. ADEWALE TROUTMAN: There’s an excellent study that was published in I believe in JAMA a couple of years ago – it’s called a chest pain study, where they took eight actors– four black, four white, four male, four female. They were all dressed exactly alike. They were all very articulate. And their persona appeared to be “all middle income,” the same, you know, educational level, et cetera.
They were given instructions. These were all actors, by the way. They were given instructions to present with a series of symptoms that was typical of chest pain that was probably cardiac in origin. These videotapes were then shown to practitioners. And the practitioners were asked to determine what they would do in the way of referral.
Now, the right answer was: These individuals should all have been referred for coronary artery angiography or some aggressive cardiac intervention because they were probably, based upon the presentation, having a heart attack or having severe unstable angina. Well, the white males were referred appropriately. Black males, black females and even white females from a gender standpoint were referred more often for GI work-up, as in, “this is not a cardiac problem. You know, take some Maalox and call me in the morning.”
And that was not the right referral. And there are lots of other instances and studies that are documented in the IOM report where there have been differences in referral patterns or access blocked for HIV medication, more likely to have certain kinds of surgery performed or more likely not to get certain kinds of surgeries based upon the need.
And these have been analyzed down to the point where the only thing different was provider attitude or perhaps an institutional bias on the part of that particular organization that was providing care.
RAY SUAREZ: Well, if, as you say, this is a factor largely due to race or ethnic origin and not social class, how do you counteract it? What do you do to start closing this gap and start taking away some of these maligned factors that you’re talking about?
DR. ADEWALE TROUTMAN: Let me also say I’m not saying that social class is not a factor. I’m saying that this particular study demonstrates that there is a bias that probably is a racial and ethnic bias not based upon socioeconomics, because all these individuals looked the same.
You must include in the formula, in the equation, income disparities and income gap disparities, asset wealth disparities. And you still must include occupation, education, housing, the social milieu in which someone lives, the availability of good social capital or not; safety in the community. The way the community is constructed as it relates to access to good nutrition, fruits and vegetables, exercise opportunities.
All of these are factors in determining what differences there may be that continue to exist in terms of the various populations that we’ve talked about. Now, to get back to the question, this conference today– as a matter of fact, it’s actually going on right now– is looking at health care and seeing where can we connect the question of disparities, health gaps and quality of care.
In other words, the IOM suggests very strongly that this issue of continued disparities in health care– remember health care is not the same as health, it’s a part of health but not the overall umbrella– that if there is discrimination, if there is bias, if there is provider attitude that negatively affects the kind of care someone gets, that is a quality of care issue.
So now, all of the experts in health care are looking at how can we monitor this quality of care issue and what kinds of parameters can we put in place to eliminate the potential bias or the potential inappropriate referrals based upon race and ethnicity and tie it to quality of care? And that is, in fact, what’s being discussed at this very moment of the conference.
RAY SUAREZ: And very briefly, we’ve talked mostly about black and white Americans.
DR. ADEWALE TROUTMAN: Yes.
RAY SUAREZ: But you’re seeing similar effects with Asians, with Latinos and others?
DR. ADEWALE TROUTMAN: Yeah, absolutely. And we looked at the black-and- white mortality gap. The most…the data that’s most readily available over time has been comparisons between the African-American community and the white community.
But since 1985, when there’s been a very intensive effort to look at the health of the nation’s “minorities,” the same patterns have been found between…within Latinos, Native Americans, Pacific Islanders, Asian-Americans, et cetera. There are some very, very basic commonalities that cut across all of the racial/ethnic groups, with some additions, obviously.
The Latino population that is not speaking English necessarily will have other issues than an African-American population will not. An Asian-American population that has a different set of cultural values and mores will have some different factors, perhaps subtly, that an African-American community will not. But when you look at all the nation’s minorities, they’re similar issues.
RAY SUAREZ: Dr. Adewale Troutman, thanks for joining us.
DR. ADEWALE TROUTMAN: My pleasure.