Race to Health
Why do African Americans consistently lag behind whites when it comes to measures of good health—and good health care?
The Miracle Temple Seventh Day Adventist Church in South Baltimore has a "For Sale" sign on its front door. But the congregation hopes to raise $350,000 to buy the building back, in order to establish what Pastor Alex Royes is calling “A Faith Center for Community Wellness Advancement.” If the plan works out, the church will be converted into a neighborhood wellness center with a clinic and health club, a place where people can seek health care as well as attend seminars and meetings—such as Alcoholics Anonymous—promoting both prevention and recovery.
The church is in a section of Baltimore known as Union Square and Montclair that has a high infant mortality rate as well as high incidences of hypertension and cardiovascular disease. There is no doubt that the residents here could benefit from an entire building devoted to advancing good health. According to 1999 census data, close to half the families here live below the poverty level, roughly three-quarters of all males do not complete high school, and about half the residents are described as “not in the labor force.” But one of the area’s unusual characteristics, at least for Baltimore, is that here, people of different races—mainly black and white—live side by side. And this makes the neighborhood particularly interesting to Thomas LaVeist, PhD.
LaVeist, associate professor of Health Policy and Management, has been pondering the issue of health disparities for much of his professional career. Why is it, he wonders, that the infant mortality rate (one of the most effective measures of a population’s overall health) is almost twice as high among African Americans as it is among whites in the United States? And why are white males expected to live eight years longer than their black counterparts? Further, why is it that black men and women are less likely to receive early screenings for breast and colon cancer and therefore have higher mortality rates for these diseases? In both health status and the way treatment is administered, study after study shows blacks lagging behind whites. And while economics plays a role in this complicated picture, having health insurance and a decent income does not eliminate race disparities in health.
The author of several studies on the issue and editor of the book Race, Ethnicity and Health, Thomas LaVeist is driven to find answers to the question that lies at the center of his work and his passions—a question that happens to be the title of his current book-in-progress: Why [do] African Americans Live Sicker and Die Younger?
LaVeist first encountered the question of survival rates among ethnic and economic groups in a used bookshop near the University of Michigan campus, where he was pursuing a doctorate in political sociology. Thumbing through a book about the sinking of the Titanic, he came across a list that categorized the percentage of female survivors based on the type of passage they had booked. “Virtually everyone with a first-class ticket survived, and it went down from there,” he says. “I thought, Wow, even on a sinking ship, your economic status determines whether you live or die.” Later, working on a study of black political power in cities, he was trying to determine quality of life in various districts. “Over and over, health indicators came up as the way to measure quality of life,” he says. Realizing that health issues were drawing his interest, LaVeist soon switched his specialty to medical sociology and followed up with a postdoc at the University of Michigan School of Public Health, and eventually made his way to Johns Hopkins in 1990.
He has been envisioning a center for the study of health disparities ever since he arrived. Now, thanks to a $6 million grant from the National Institutes of Health (NIH), Hopkins will join forces with Baltimore’s Morgan State University to create the Morgan-Hopkins Center for Health Disparities Solutions . With the new Center’s other director, Morgan professor of public health Dorothy Browne, LaVeist will embark upon a mission of educating researchers, working with community organizations to address disparities, and conducting primary research. Perhaps most important, the new Center will try to see that the issue of health disparities is recognized and understood by the public, the health care industry, and policy makers.
As one of its first undertakings, the new Center is casting its eye on the Union Square and Montclair neighborhood that surrounds the Miracle Temple. Students will interview and screen each of the 3,555 adults in the area, LaVeist says, to determine such basics as blood pressure, weight, and medical conditions. And the students will probe the residents’ lifestyles, their home environments, and the substances they take into their bodies.
Over time, the project is meant to determine how these details correlate with health outcomes, LaVeist says, and to answer the question, “Is there a racial disparity in health after adjusting for the characteristics of the community?” After all, says LaVeist, “The people here are exposed to the same environmental hazards and living conditions.” And while there doesn’t seem to be much racial strife, he wryly points out that the neighborhood isn’t lacking for tension: The residents, here, he says, “live together, hang out together, sell drugs together, break into cars together.”
The inequities between health care delivery to blacks and whites captured the public’s attention in 1999, with a study published in the New England Journal of Medicine. The study enlisted actors, both African-American and Caucasian, to portray patients with various heart-related health complaints. Their visits to doctors were then videotaped. The tapes revealed that even when these “patients” presented with identical symptoms, the doctors’ referrals varied widely according to race, with African-American women receiving the fewest referrals for cardiac catheterization—a crucial next step to diagnosing heart disease.
The study, by Kevin Schulman, then at Georgetown (and now director of the Center for Clinical and Genetic Economics at Duke University), was featured on TV’s Nightline, where it sparked a public uproar and caught the attention of Congress. The Department of Health and Human Services commissioned a study by the Institute of Medicine (IOM), an independent organization frequently called upon to advise the federal government. The IOM’s mandate? To determine whether there are differences in care among racial groups.
A panel of 15 experts (including Martha Hill, dean of the Johns Hopkins School of Nursing, and Donald Steinwachs, chair of the Department of Health Policy and Management at the School of Public Health) convened to sort through the available research for some answers. The resulting report, “Unequal Treatment,” was released in March 2002.
This was not an empirical study, according to Brian Smedley, who as senior program officer for the IOM directed it. Rather, it was an analysis of more than 100 published papers, including some by LaVeist, to examine whether there are differences in the care that minority groups receive compared to whites, and further, to determine whether disparities continue to occur even after variables such as insurance and income status have been controlled for.
After its 18-month review, the committee could only conclude that the reasons for health care disparities are myriad and complex. Cultural and language barriers, time limitations imposed by managed care, and a general distrust for the health care establishment on the part of minority patients can all contribute to unequal treatment. But one of the panel’s most significant conclusions is one that many doctors would vehemently deny: that those in the medical profession bring bias, racism, and stereotypes to the patient/provider relationship. Says Smedley, “We may harbor stereotypes that we are not consciously aware of.”
Notes LaVeist, “There are many assumptions about the differences between blacks and whites.” He points to a 2000 study in Annals of Emergency Medicine, in which blacks and Hispanics visiting the emergency room were less likely than whites to be prescribed pain killers for broken limbs. The unspoken inference, perhaps dating back centuries to the time of slavery, was that blacks have a higher tolerance for pain than whites. “This is an egregious example of unequal treatment,” he says. “Much of what happens is much more subtle.”
For better or for worse, time-pressed practitioners may unwittingly rely on racial stereotyping, says Donald Steinwachs, PhD. “One of our human strengths is generalizing. When we meet someone, we often make assumptions about their education and background based on their resemblance to other people we have known,” he says. But it’s also one of our weaknesses. In doing so, we may not listen as carefully.” And this, he believes, may be a failing in clinical encounters.
LaVeist tells of his sister’s experience when she learned she was pregnant. “The doctor immediately began counseling her on options for abortion and adoption. She said, ‘I guess I would have to discuss this with my husband and two children.’” LaVeist laughs and says: “I don’t think the doctor was consciously saying to himself, ‘This is a black woman, she must be poor and unmarried.” Nevertheless, something like this assumption apparently affected his approach to his patient.
LaVeist himself had a similar encounter: Working out at his gym one day, he hit his head badly. “There was a lot of blood, so they took me to the emergency room,” he recalls. There, an intake nurse took one look at him and said, “You don’t have health insurance, do you?” LaVeist informed her that, yes, he was insured. Once he revealed his occupation and his employer, he says, “everything changed. Instead of giving me a Band-Aid and sending me home, I was suddenly getting the best quality health care anywhere.” Not all black males, insured or not, he suspects, are so fortunate. “A lot of times patients don’t even know they have been victims.”
While health disparities are “obviously a life or death issue among people of color,” the IOM’s Smedley says, the issue should be of grave concern to everyone. If subjective considerations affect the quality of care an individual receives, he points out, “this presents a serious problem for all Americans.” Who’s to say where such subjectivity could strike next?
If ingrained prejudice and racism do indeed exist, what can be done about it? The IOM report called for “comprehensive solutions at the federal level,” including close monitoring of present disparities, such as rates of infant mortality, life expectancy, and cancer survival, says Smedley. The public, health care providers, insurance companies, and policymakers should be made aware of the problem, the panel concluded. And health institutions should introduce policies—such as evidence-based guidelines—to ensure consistency in treatment and referrals. In addition, says Smedley, “steps need to be taken to increase the diversity of health care providers.”
Although the report found that the quality of care doesn’t seem to be better when the doctor and patient are of the same ethnicity, concordance of race can make a difference in a patient’s perception of care. According to a 2002 study by LaVeist and Johns Hopkins doctoral candidate Amani Nuru-Jeter published in the Journal of Health and Social Behavior, patients “who were race-concordant” with their physicians “reported greater satisfaction” with their treatment. The findings led the authors to recommend “support for the continuation of efforts to increase the number of minority physicians, while placing greater emphasis on improving the ability of physicians to interact with patients who are not of their own race.”
Says LaVeist, “Patient satisfaction is an important component of quality care. We know from previous studies that a patient’s comfort level will determine compliance.” Of course, a patient following the prescribed treatment regime will be more likely to achieve the best results.
The Urban Medical Institute (UMI) in the Park Heights section of West Baltimore occupies the campus of what was once Liberty Hospital, the city’s first black hospital. Purchased by Bon Secours in 1996, the facility’s new mission is to provide clinical services and community outreach for the Park Heights community. Most of the doctors here look like the patients they treat. Pat Schmoke, wife of former Baltimore Mayor Kurt Schmoke, runs a busy ophthalmology practice on the second floor, not far from the offices of Athol Morgan, a Johns Hopkins–trained cardiologist renowned for achieving high rates of patient compliance and survival. Both are African-American.
When the Institute was established, LaVeist took a six-month leave of absence to work at UMI in an effort to “create a research infrastructure.” In other words, he helped to establish protocols for taking patient data and tracking maladies—information that continues to prove invaluable in his research. Institute director Phil Christian takes great pride in UMI’s contributions to LaVeist’s work. “He is intimately knowledgeable of this population, and his perspective is extremely important to where we are,” Christian says of LaVeist. “Whenever he publishes something, those of us at ground zero believe it.”
In his work at the Institute, Christian has identified a related disparity: differences in pay scales and the costs associated with medical services between public and private facilities.
Hopkins’ Darrell Gaskin, PhD, deputy director of the new Center for Health Disparities Solutions, points to a related issue: “Medicaid reimbursements are woefully inadequate for physician care,” he says. “Where Medicaid is a dominant player,” as it is in many disadvantaged African-American communities, “physicians can’t make a living. In fact, Medicaid typically pays less than what it costs a physician to provide the service,” leading doctors to reject Medicaid recipients. This prompts Medicaid patients to visit hospital emergency departments, even for routine health concerns—further burdening cash-starved hospitals. In the Miracle Temple’s 21223 ZIP code area, residents make more than 30,000 emergency department visits per year. More than 30 percent of those visits are not related to actual emergencies. Gaskin, who worked on the Maryland Healthcare for All! coalition, a grassroots group that in 2002 issued a plan for affordable health care for all of the state’s residents, is a strong proponent for a universal health insurance system.
While the federal government may not be ready to announce an upgrade of Medicaid reimbursements or a national health plan, it has nevertheless taken some action. As a result of the “Unequal Treatment” report, Congress passed a law authorizing the establishment of a national Center on Minority Health and Health Disparity. It also allocated money through a program called “Centers for Excellence” to fund local research programs. The Hopkins/ Morgan collaboration is one of the first recipients of these grants. “Hopkins and Morgan are a good match,” says Jean Flagg-Newton, chief of the Office of Research at this new Minority Health Center at NIH. Flagg-Newton says that Morgan and Hopkins complement each other, offering strong research and a passionate interest in the community that surrounds them.
No Plans “to Just Walk Away”
Morgan’s Dorothy Browne is determined that no confusion arises about the “Solutions” part of the Center’s name. “We aren’t planning to go in and do our research and walk away,” she says. Browne, DrPH, director of the Prevention Sciences Research Center and Drug Abuse Research Program at Morgan, headed numerous studies in adolescent and maternal/child health as a professor at the University of North Carolina’s School of Public Health in Chapel Hill, and much of her work has involved community-based research.
“As researchers,” she says, “we often think the community won’t understand what we’re doing, so we don’t bother to tell them.” But, she notes, this fuels distrust and the fear of exploitation. Good research, she believes, requires cultural sensitivity. She recalls a study in North Carolina in which respondents were deeply offended because researchers addressed older African-American women by their first names.
In South Baltimore, both Browne and LaVeist are working hard to engage the community from the start: Community leaders and residents will be paid as investigators and participate in planning and policy meetings. The neighborhood will not be referred to as a “laboratory,” and its residents are not “subjects.” In fact, at biweekly meetings attended by the researchers, pastors Frederick Russell and Alex Royes, and leaders from the community, “the community drives the agenda,” says LaVeist.
Once all the statistics have been gathered, LaVeist says, “the information will be put to good use.” For example, he says, “We may use what we know about the success of various smoking cessation programs to help the community go after funding and implement some [proven cessation programs] here.”
The Miracle Temple study is in its nascent phase, but it is already the beneficiary of some solid information. Alex Royes spent the summer of 2001 collecting data about the community for the Columbia Union Conference of Seventh Day Adventists. The organization conducted similar surveys in four other Eastern cities “to pinpoint specific needs in communities” in order to assist pastors with their work, Royes says. He started his job as a minister here in September but already has a strong sense of how the community works. He knows that the drug of choice is heroin, that there is a high incidence of diabetes, and that many interracial children are playing in the streets. There are numerous and varied fast food restaurants, but fresh vegetables are hard to find.
For Thomas LaVeist, the neighborhood is a researcher’s paradise, the perfect place to pursue his goal: “To create a long-term relationship so we can apply public health science to a specific community and improve its health.”