Sidney D. Watson
Excerpted from: Sidney D. Watson, Race, Ethnicity and
Quality of Care: Inequalities and Incentives , 27 American Journal of
Law and Medicine 203-221, 205-210 (2001)(131 Footnotes Omitted)
As was my custom, I moved from one exam room to the next with a
fluidity that comes from years of practice, yet I was stopped in my
tracks when Mr. North rose to his feet to greet me. His deep ebony,
six foot>three>inch
frame dwarfed my pale, five>foot>three
presence. The tremendous hands on his 260 pound body grabbed my own
outstretched right hand and shook it .... I glanced at his face,
trying to see through my initial discomfort, only to be greeted by my
own face staring back at me from the silver, reflective sunglasses he
wore beneath a baseball cap that covered his head and any hair that
might have been growing on it. His huge chest was tightly wrapped in a
black T> shirt that, even in its
largest version, couldn't stretch comfortably to encompass his
pectoral girth .... Mr. North became one of my favorite patients ... I
like him because I realize how hard I have had to work all of my life
to overcome the racist feelings that made me fear him when we first
met and that never allow me to act completely naturally in his
presence. . . . There is absolutely no doubt that Mr. North is treated
differently than my white, middle>class
patients. The echocardiography lab where he had an appointment sent
him home because he was ten minutes late, having to stop every block
to rest in the walk from his home to the hospital on a particularly
windy day. The pharmacy refused to refill his insulin syringes without
a written prescription, even though he had been getting them at the
same pharmacy for the past two years. I try to help in every way I
can. Every time I send him to a new consultant, I call ahead with an
introduction. I tell them how smart Mr. North is, how compliant he is
with every aspect of his treatment, and how he knows so much about his
medical condition and the medications he takes. I hope that my
introduction will enable them to see my patient as I see him now, not
as I saw him the first time we met. He needs that help in order to get
the medical care he requires and deserves.ö
Race matters. A plethora of studies and reports document that the
patient's race makes a difference in the care received. Race and
ethnicity are consistently linked with different and poorer patterns of
health access and treatment.
Minority Americans have significantly higher rates of cancer, stroke,
heart disease, AIDS, diabetes, and other severe health problems than
white Americans. However, even though minority Americans are generally
in worse health than white Americans, they have fewer doctor visits,
receive less primary care and fewer preventive procedures even when they
have the same insurance coverage. Insured Blacks and Hispanics are less
likely than whites to have private physicians and are more likely than
whites to rely on hospital emergency rooms and outpatient clinics for
primary care. As a result, Black, Hispanic and Native Americans are
hospitalized more often than whites.
Moreover, health care professionals provide different>>and
generally less>> care to their
minority patients. When hospitalized, African>Americans
receive fewer surgical interventions, diagnostic tests, medical
services, and less optimal interventions than whites>>even
when their diagnosis, symptoms, and source of payment are the same. The
findings for African>Americans are
consistent for every service studied: cardiology and cardiac surgery,
obstetrics, general medicine, kidney transplants, hip replacements,
mammograms, oncology and leg sparing surgery for peripheral vascular
disease. All told, African>Americans get
only about three>quarters the high
technology interventions prescribed for whites. They are more likely to
be discharged in an unstable condition and more likely to have longer
hospital stays.
Outpatient care is no different. African>American
patients are less likely to be prescribed antidepressants for major
depression and anti> retroviral therapy
for HIV infection. They are also less likely to get adequate treatment
for cancer>related pain.
While less is known about access and treatment for other minority
Americans, the few available studies confirm that Hispanic and Native
Americans suffer from similar treatment disparities. Both Hispanic and
Native Americans are significantly less likely than whites to receive
cardiac bypass surgery and angioplasty, and Hispanics are less likely to
receive other major therapeutic procedures. Hispanics are also less
likely to get adequate treatment for cancer>related
pain, and are twice as likely as white patients to receive no pain
medication when treated in the emergency room for bone fractures.
These race>based treatment
differences raise concerns about the quality of medical care for
minority Americans. They are not the result of biology, age, gender,
clinical condition, severity of disease or insurance status. Contrary to
popular belief, the gaps cannot be attributed to insurance status or
income: significant differences exist even when these factors are
controlled for. Although most studies merely document disparities in the
rates of procedures based upon the patient's race and ethnicity, those
that examine the actual quality of care provided to patients tend to
confirm that minority patients not only receive less care, but poorer
quality care.
Thus, race>linked disparities signal
some kind of error. Some may be mistakes in judgment>>the
result of a wrong belief or misapprehension about the disease or
patient's race, ethnicity or class. Other disparities may be the result
of ignorance, carelessness or oversight. Many are likely the result of
poor communication. Some may be transgressions of law. All are colored
by America's history of slavery and segregation.
Minority patients do not always trust white caregivers or the medical
care system. Caregivers may carry deep>seated,
often unconscious stereotypes about patients of other races and ethnic
groups. Class differences are likely to accentuate and complicate racial
and ethnic differences. Cross cultural and cross>class
communication can be difficult not only when the participants speak
different languages, but even when they appear to share a tongue.
Individual institutions and the health care system retain vestiges of a
formerly segregated system that compound the problem. Residential and
geographic segregation mean that health care providers do not locate
their practices where large numbers of minority patients, particularly
poor minority patients, live.
In America, race is not just a skin color, and ethnicity is not just
culture. Race and ethnicity are social categories that reflect
differential access to power and social resources. Throughout American
history, law and custom have relegated minority groups to different>>and
inferior>> treatment. Medical care is
no exception. Understanding racial disparities in medical care requires
an appreciation of the history of racism, segregation and civil rights
in medicine. Today's health care is rooted in the past.
