The Great Divide

Mary Carmichael, Newsweek, February 17, 2010

{snip}

In the years since the report [Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, an Institute of Medicine report], the issue has gotten plenty of publicity, more reports have come out, and several agencies–including the National Center on Minority Health–have examined the problem and suggested solutions. Still, studies continue to turn up disturbing disparities. For instance, earlier this month, a paper from the Fred Hutchinson Cancer Research Center found that between 1992 and 2004, black women were up to 90 percent more likely to be diagnosed with advanced breast cancer than white women, even though rates of mammogram screening were similar for the two groups. Another recent study put the health data in financial terms and found that race-related differences in health care cost the country $229 billion between 2003 and 2006, a result that Health and Human Services Secretary Kathleen Sebelius called “just stunning and shocking.”

So why, now that everyone’s aware of the problem, do we still have one? Mostly, the reason is that health and race are both complicated issues to examine academically. {snip}

Take the simple issue of how to classify people in order to study health disparities. Let’s say you want to look at Hispanics. “They’re a group that is linked only by being from countries that were under Spanish rule,” says Thomas A. LaVeist, director of the Hopkins Center for Health Disparities Solutions. “To combine Cubans and Mexicans and everyone else into one category doesn’t make a lot of sense. The populations are so different. You have a tremendous amount of variation [in health, lifestyle, and genetic heritage] that’s being masked.” Or take the fact that studies often put Africans living in the U.S. in the same category as African-Americans who were born and raised here. If you want to study, say, HIV rates, that catchall category becomes meaningless, says LaVeist, because the virus is so much more prevalent in Africa.

Then there’s the thorny issue of causation. Almost all common health problems have two root causes: the “nature” ones (i.e., genetic factors), and the “nurture” ones, which come from one’s environment. For minority health issues, both categories are complicated. Race is a notoriously inaccurate proxy for genetics, since it’s such an imprecise way of describing people. Take the case of Bidil, the so-called black heart-disease drug. {snip}

The “nurture” category is even more complicated, because it encompasses both the social environment (how people live, their income, what they eat, how stressed-out they are) and the medical environment (whether doctors are treating them differently because of their race). {snip}

Take diabetes, which is far more common in African-Americans and Hispanics than in whites. Both Sequist and LaVeist have looked at the issue extensively. Sequist’s work has found that “the health system in general got much better for diabetes care” for minorities from 1999 to 2003, thanks to “cultural competency” training for doctors. In one study, physicians were treating patients of different races exactly the same way by the end of the training. But the minority patients’ outcomes actually got a little worse over the same time period. Similarly, LaVeist has looked at “a community with black and white people living together, in the same conditions”–specifically, a neighborhood in southwest Baltimore–and found that “there was no race difference with diabetes.”

{snip}

All these complications make it extremely difficult to implement good policies around race and health. And yet, says Sequist, “about three or four years ago, there was a huge push to move into the phase of actually doing something about this.” Cultural competency training has now become standard in many medical centers. {snip}

But health-care reform probably won’t be enough to change the fact that minorities are more likely to be in poor health. {snip}

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