Shall We Overcome?

The Civil Rights movement achieved its original stated goals with the Civil Rights Acts of 1964 and 1968, the 1965 Voting Rights Act, and important Supreme Court rulings from the 1950s through the '70s. These changes in the law were accompanied by a growing societal consensus that discrimination based on race or ethnicity is completely unacceptable. Basking in the glow of these achievements, during the 1980s and 1990s most people involved in the medical institution presumed that racial or ethnic inequality in the provision of medical care was in the past. Racial and ethnic disparities in health status persisted, but most people presumed that this resulted from social determinants of health, and perhaps from lack of access to medical care for financial reasons, and had little or nothing to do with the health care people actually received once they did get in the door.

In the New American Century, we have learned the truth. In 2002, the Institute of Medicine published its famous report Unequal Treatment (Smedley BD, Stith AY, Nelson AR eds. Unequal Treatment: confronting racial and ethnic disparities in health. Institute of Medicine (U.S.), Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care. Washington, D.C. 2002), which reviewed hundreds of studies and concluded that racial and ethnic disparities in the provision of medical services are ubiquitous. Congress mandated the Agency for Healthcare Research and Quality to produce an annual report on healthcare disparities, and yup, they're still happening. (U.S. Agency for Healthcare Research and Quality. 2004 National Healthcare Disparities Report. Available at the AHRQ web site. The Commonwealth Fund does national surveys of healthcare consumers every five years and they find that consumers report unequal treatment. (Collins KS, Hughes DL, Doty MM, Ives BL, Edwards JN, Tenney K. Diverse communities, common concerns: assessing health care quality for minority Americans. Findings from the Commonwealth Fund 2001 Health Care Quality Survey. The Commonwealth Fund. New York, 2002.)

Now three articles in the new New England Journal of Medicine inform us that these disparities have not spontaneously disappeared, indeed have remained the same or have even increased. What this means is that people don't prescribed the drugs they need, don't get surgery that can save their lives or alleviate disabilities, don't get appropriate diagnostic tests, stay sick, stay disabled, and die, when other people whose ancestors mostly happen to come from western Europe don't.

This should not come as a surprise. To quote Brian K. Gibbs of the Harvard School of Public Health, speaking at a symposium sponsored by the New England Coalition for Health Equity in December of last year:

To present a historical context, let me use the example of the experience of African Americans in health care. From the time that Africans were brought to America in 1619 and for the next 246 years -- or about 64% of the African experience in America so far – they experienced a slave health sub-system. Slaves were provided with health care, and the basic conditions for health, only if there was an economic benefit to the owner. From 1865-1965, the period from the Emancipation Proclamation to the Civil Rights Movement, for another 100 years – the next 26% of our time here -- there were no citizenship rights, inferior housing, education, healthcare – in much of the country a separate subsystem of healthcare. From 1965 to 2004, which is 10% African Americans’ experience, they have enjoyed most of the rights of citizens, at least under the law.

Now today, although we can create policies that specifically address the health care system or perhaps address specific disease categories, is this enough to overcome the internalized and interpersonal types of racism experienced in society? For 385 years, this racism has existed, it didn’t start with the IOM report.

In discussing the issue of "disparities," we always look for other explanations: African American and Latino patients have different preferences -- they want less health care, for some reason they don't want their coronary arteries unblocked; they have difficulty communicating with their physicians; there must be some mysterious biological differences among people of different ethnicity who have the same diagnosis, that causes physicians to make appropriately different treatment choices.

Nope. Racism is deeply internal. It is an infection of the mind, and highly resistant to treatment. We need a Manhattan Project of research and treatment.