Racial and Ethnic Disparities in Health and Health Care Kevin Fiscella, MD, MPH University of Rochester School of Medicine & Dentistry Departments of Family Medicine Community & Preventive Medicine
What is race? How we define race strongly affects how we conceptualize the relationships between race and health and health care.
What is race? • “A group of people of common ancestry distinguished by physical characteristics such as hair type, eye or skin color, etc.” -Collins English dictionary, 1998 • Geographic origin of ancestry –1997 OMB standards • “Ideology of inequality devised to rationalize European attitudes and treatment of the conquered and enslaved peoples.”- American Anthropological Association Statement, 1998
What is ethnicity? • Shared cultural, national, religious or linguistic heritage • Hispanic or non-Hispanic origin –1997 OMB standards
Racial and ethnic disparities in mortality • African Americans have the highest age-adjusted mortality rate of any group, followed by whites, American Indians/Alaska Natives, Hispanics, and Asians, Native Hawaiians or other Pacific Islanders. • Deaths for American Indians/Alaska Natives and Hispanics tend to be misclassified on death certificates, so vital statistics underestimate mortality rates for these groups.
Disparities in cause-specific mortality • Blacks have higher death rates than whites from all the leading causes of death except suicide and chronic lung disease. HIV death rates are 10 times higher and homicide rates are more than 7 times higher among blacks than whites. • Hispanics have 3 times higher rates of death from HIV and homicide than whites and higher rates from liver disease and diabetes, but lower rates than whites for all other major causes including heart disease and cancer.
Disparities in cause-specific mortality • Asians have lower death rates than whites in all categories except homicide. • American Indians/Alaska Natives have higher death rates than whites from liver disease, diabetes, HIV, accidents and homicide, but lower death rates from heart disease and cancer.
Life expectancy for African Americans is nearly six years less than whites • Disparities in socioeconomic status explain much of this gap. • Disparities in cardiovascular mortality explain nearly one third of the gap. • Hypertension represents the single largest contributor to this gap.
Black-white disparities in health begin in utero • Black infant mortality rate is two and half times higher than that of whites. • Most of this gap is due to racial differences in rates of very low birth weight. • The primary causes of very low birth weight are intrauterine infection and hypertensive disorders that result in preterm birth. • Sudden infant death is the major cause of racial disparities in post neonatal mortality.
Black-white disparities in maternal mortality • African American women die during pregnancy and child birth at five times the rate of whites. • The primary causes of this gap is disparities are vascular and infection related complications and homicide.
Fundamental causes of racial disparities in health and well being • Poverty • Segregation • Racism
Poverty • More than one out of three black children under the age of 6 lived in poverty in 2000 (twice the rate of whites). • Blacks earn on average 62% of that of whites. • Among equivalent income or educational levels, blacks have far less wealth than whites.
Segregation • African Americans experience greater and more persistent residential segregation than any other group “hypersegregation.” – Massey, 1989 • Residential segregation and confinement to impoverished central cities has a devastating impact on the economic, educational, psychological, and physical well-being of African Americans. –Williams, 2002 • Segregation undermines social cohesion, reinforces individual, institutional, and internatalized racism.
Racism Institutional and individual practices that create and reinforce oppressive systems of race relations whereby people and institutions engaging in discrimination adversely restrict by judgment and action, the lives of whom they discriminate against.-Krieger 2003
Categories of racism • Individual racism- Ideology of inherent, biological superiority of one race over another that is used to justify discrimination. • Institutional racism- Policies and practices that systematically reinforce the power and privilege of one racial group over another. • Internalized racism - Introjection of pejorative messages by stigmatized racial group regarding their capabilities and behavior.
These categories reinforce each other • Unconscious racist assumptions (individual racism) result in national, state, and local policies (institutional racism) that reinforce racial stratification. Examples include educational, correctional, and economic policies. • Persistent poverty, despair, stigma, and loss of community role models reinforce internalized racism.
Context matters • Poverty, segregation, and racism do not operate in isolation from each other. It is the confluence of these factors that undermines the well being of African Americans. • Current conditions cannot be understood in the absence of their historical context. • The impact of poverty on a black child growing up in the inner-city is qualitatively different than that of a first generation Mexican or Asian child.
Race and genetics • Race is a social construct without biological basis; there is far greater genetic diversity within racial categories than between them. • Because race is associated with geographic ancestral origin and because differences in geographic origin are associated with genetic allele frequency, allele frequency occasionally differs by race. • These differences do not negate the social construction of race. • Only a few conditions result from the effects of single alleles. Genetic differences by race are unlikely to explain most disparities in chronic diseases.
Causal pathways across the life course • The pathways through which racism, segregation, and poverty affect black well-being are complex. • Effects early in life may have lasting effects, e.g. fetal nutrition, lead toxicity, cognitive stimulation. • Risk factors among disadvantaged groups tend to cluster and generate downward trajectories. • Risk factors tend to have cumulative effects over time.
Specific mediators of disparities • Intrauterine environment - Fetal origins of disease hypothesis suggests that low birth weight infants are at higher risk for diabetes, hypertension, obesity, renal disease, and heart disease. • Physical environment - Exposure to lead and other toxins, violence, availability of food, alcohol, and illicit drugs. allergens, passive smoke, crowding, infections, and diet. • Family environment - Presence of two adult age parents, early cognitive stimulation, absence of abuse, and role models. • Social environment - Impact of peers, expectations of future, risk of violence, opportunities for self expression, social network and support, and opportunities for marriage.
Specific mediators of disparities • Psychological environment - Psychosocial stress from discrimination, autonomy/control, stigma, and internalized racism. • Educational environment - Levels of expectations, concentration of students at risk, and resources. • Work environment - Job opportunities, control of work, opportunities for advancement, risk of physical injury. • Cultural environment - Norms of health related behavior e.g. breast feeding, infant sleeping position, douching, attitudes towards immunizations and health care. • Health care environment – Large disparities documented.
Exposure to toxins, allergens, & infections Racism segregation Intrauterine effects Childhood poverty Cognitive stimulation Marriage Family function Community decline Access to health care cognitive and emotional development Peer effects Access to social networks behavior stress Educational achievement employment Adult poverty Health
Racial and ethnic disparities in health care • Disparities differ by type of health care and by racial and ethnic group. • Disparities are best documented and most severe for African Americans.
Disparities in types of health care • Preventive services • Medical treatment • Surgical procedures • Interpersonal care
Disparities in preventive care • Prenatal care (number of visits and quality) • Child immunizations • Well child visits • Adolescent immunizations • Pap smear screening • Breast cancer screening • Colon cancer screening • Influenza & Pneumococcal immunization • Smoking cessation advice
Acute & chronic pain Asthma Chemotherapy Congestive heart failure Coronary artery disease Depression Diabetes Dialysis HIV Hypertension Myocardial Infarction Pneumonia Stroke Disparities in medical treatment
Disparities in surgical or invasive procedures • Organ transplantation • Curative cancer surgery • Cardiovascular procedures/surgery • Cerebrovascular procedures/surgery • Hip and knee replacement surgery
Disparities in satisfaction and interpersonal care • Health care satisfaction • Physician satisfaction • Physician trust • Involvement in care • Perceived discrimination
Causes of disparities in health care Societal factors - Differences in presence and type of health insurance and systems of care. Patient factors - Literacy, knowledge, beliefs, attitudes, language and norms. Physician factors - Unconscious stereotyping, cultural insensitivity, and poor communication skills
Societal factors • More than 50% of Hispanics and 40% of African Americans lacked health insurance at some point during 2001. • Minorities more likely to be seen by residents. • Presence and type of health insurance contribute to, but do not fully explain, disparities in health care.
Patient factors • Patients beliefs, attitudes, knowledge, preferences and literacy contribute to disparities. • Patient factors do not fully explain disparities. • Patient factors are strongly influenced by system and provider factors.
Physician factors • Overt prejudice - “I won’t recommend bypass surgery because this patient is black.” • Stereotyping - “I won’t recommend kidney transplantation because most blacks do not adhere to treatment.” • Clinical uncertainty - “I won’t recommend angiography because the patient’s symptoms are too dramatic (or not dramatic enough) to warrant the risk of this procedure.” • Poor communication - Absence of patient-centered care and patient-physician partnership.
Patient-centered care • Represents a core dimension of health quality as defined by the IOM. • Involves a set of core communication skills necessary to insure patient involvement in their care. • Skills include obtaining knowledge of the patient as a person, eliciting the patient’s perspective on their condition. • Explaining treatment options in understandable terms. • Eliciting the patients preferences for treatment • Confirming the patient’s understanding of the specifics of the treatment plan.
Minorities receive less patient-centered care • Physicians adopt a more directive style, provide less information, and engage in less partnership with minority patients. • The result is lower rates of adherence and lower quality care.
Equity is a core dimension of quality • Equity recognized by the Institute of Medicine in 2001. • Quality assurance must include measures of disparity. • Quality Improvement represents an important means for addressing disparities in care. • Recent data suggest that quality improvement reduces disparities.
Implications for addressing disparities in health & health care • The Healthy People 2010 goal of eliminating disparities in health requires addressing fundamental causes of disparities. • Academic-community partnerships represent an important means for addressing fundamental and proximate causes of disparities at the local level. • The elimination of disparities in health care will require initiatives leverage existing quality improvements efforts that address physician and patient factors. • Quality improvements offer the greatest potential for change when they are strongly tied to the community. • Disparities in access including insurance must be addressed