“Closing the Gap: Implementing Solutions to Health Care Disparities in New York”Daniel Laroche MDPresident, Empire State Medical Association,NYS National Medical Association affiliateAssistant Professor OphthalmologyNew York Medical CollegeNew York Eye and Ear InfirmaryPresident, Advanced Eyecare of New York
AMA History with respect to Black Physicians 1870: The integrated National Medical Society delegation was excluded from the AMA Annual Meeting in Washington, D.C. 1874: The AMA adopts a system of governance allowing state medical societies to determine which local societies will be recognized at AMA meetings, effectively allowing each state to decide the question of racial segregation. 1910: The AMA-requested Flexner Report, Medical Education in the United States and Canada, is published; the report recommends that all but two black medical schools be shut down. 1939: The AMA discontinues its policy of listing black physicians as "colored" in its American Medical Directory. The House of Delegates adopts policy discouraging racial discrimination in constituent society membership but allows it to continue. 1965-1968: The National Medical Assn. and the Medical Committee for Human Rights picket the AMA's meetings, protesting the Association's lack of action on state and county medical societies' racial exclusion policies.
American Medical Association Apology, July 2008 The American Medical Association officially apologized in July for its history of excluding black physicians from membership, for listing black doctors as "colored" in its national physician directory for decades, and for failing to speak against federal funding of segregated hospitals and in favor of civil rights legislation. "The AMA failed, across the span of a century, to live up to the high standards that define the noble profession of medicine," said AMA Immediate Past President Ron Davis, MD, Journal of the American Medical Association. July 2007 Hawaii July 2008 Atlanta
Some Progress has been made • There are about 48,000 physicians in New York State • About 3,024 are self described as Black non Hispanic • Population of New York is 9 million with a Black population of 1.8 million • White physician/patient ratio is 1/150 • Black physician/patient ratio is 1/595
Study on Black Physicians in NY The number of Black physicians has not increasedsubstantially over the past decade and remains far less than their corresponding proportion in the state’s population. Black physicians are more likely to practice in a primary care specialty and work in hospitals and clinics. They are alsomore likely work in areas of the state that are federally designated as primary care shortage areas. Black physicians, improve the diversity and cultural competency of the physician workforce, can increase access to care and quality of care for underserved populations in New York
Study on Black Physicians in NY • Black physicians were more likely to serve a higher percentage of Medicaid patients in their practices compared to all other physicians. • About one-third of Black physicians reported patient case loads of at least 50% Medicaid patients compared to slightly more than 11% of all other physicians. • There continues to be a tremendous shortage of Black physicians in New York State Source: NYS Education Department Physician Re-licensure SurveyThe Center for Health Workforce Studieshttp://chws.albany.edu
Cardiovascular Disease • Blacks in NY are 55% more likely to die of heart disease compared to whites at ages 45-54
Cardiovascular Disease • In the last 15 years heart disease hospitalizations increased in excess of 40% in eight mostly low-income neighborhoods: • Especially in Brooklyn • Increase of 94.4% in East New York • Increase of 78.5% in Bedford Stuyvesant-Crown Heights • Increase of 56.2% in Flatbush-East Flatbush
Cancer • Black New Yorkers are 46% more likely to die from cancer than whites ages 45-54 Gregory Hines Famous Tap Dancer Died of liver cancer At age 57 Ben Carson Famous Neurosurgeon Survived Prostate Cancer
Breast Cancer • The incidence of Breast cancer is over 40% higher among white women however more Black women die from Breast Cancer Breast Cancer Stamp
Diabetes • In NY, 20% blacks suffer from diabetes • In the last 15 years hospitalizations have doubled in • South Bronx • East Harlem • Central Brooklyn In 2005 the costs of an additional 3,100 hospitalizations in the bottom two sixths neighborhoods was $37 million. Much of it paid by the public through Medicaid or hospital charity pool.
Obesity • 50% of Black women are obese • This increases risks for hypertension, heart disease, diabetes. • Black high school students in NY report the lowest rate of physical activity (over past 7 days), but the highest rate of television watching of 3 or more hours per day.
AIDS • 50% of AIDS-related deaths in the city occur among blacks, who account for 25% of the city's population. • In addition, black women account for 34% of the city's new AIDS cases • Approximately one in five black men ages 40 to 49 living in the city is HIV-positive • Statewide, girls and women account for 48% of new HIV cases among people ages 13 to 19, and HIV prevalence among black women is more than 27 times higher than prevalence among white women • Black high school students report the highest rate of sexual intercourse and of forced sexual intercourse among female students New York City Department of Health and Mental Hygiene
ASTHMA • In NY, children in poorer neighborhoods are 3x as likely to be hospitalized for asthma than children living in wealthy neighborhoods. • Although the adult incidence of asthma are similar for Whites, Blacks and Hispanics, the death rates due to asthma is more than four times higher among Blacks than it is among whites Rap star Coolio suffers from Asthma and is a spokesperson For the Asthma and Allergy Foundation
GLAUCOMA Kirby Puckett had to Retire early from Baseball and loss vision In one eye from glaucoma • Leading cause of blindness in the African-American and Afro-Caribbean community • Blindness rates from glaucoma are 4-6x higher in Blacks than whites Ray Charles went Blind from glaucoma At age 6 Surgical Undertreatment of Glaucoma in Black Beneficiaries of Medicare: Archives of Ophthalmology Vol 118, Feb 2000
Infant Mortality • In NY in 2006, the infant mortality of Black babies is 2-3 x that of whites.
Lead Poisoning • In the year 2004, 6,200 children were identified with lead poisoning, 94% of the children are black • This continues to occur despite the fact that the NYC Dept. of Health banned lead based paint over 40 years ago
Substance Abuse • New Yorkers living in poorer neighborhoods are 4 times more likely to be hospitalized for substance abuse than those that live in wealthier neighborhoods.
Mental Illness • Poorer New Yorkers are more than 2-6x more likely to experience serious emotional distress than those with higher incomes • Rate of Mental Illness in Fordham and Bronx Park 13% • Whereas, the rate of Mental Illness in wealthier Riverdale is 3%
Homicide • For Brooklyn, roughly one in every 53 black 15-year-old males will die from homicide before reaching their 45th birthday. • By contrast, the average 15-year-old U.S. male faces a very low one-in-185 probability of being murdered before reaching the age of 45. • Most of this violence is Black on Black Violence.urdered before reaching age 45. • Chance of being a murder victim • White female 1:606 • White male 1:106 • Black female 1:124 • Black male 1:29 Councilman James Davis WK Kellogg Foundation, CDC
Prisons • In NYS the jail budget is higher than the state education budget • Costs $40,000 yr to keep a prisoner in jail, this is enough money for a college Education • In Suffolk County NY Blacks make up 55% of the prison population and only 5% of the county • 63% of Black jail inmates were found to have a mental health problem • Being in jail is the single most deterrent to employment
What are the Life Expectancy and Death Rates? • Average life expectancy is: 71.8 years for African Americans 77.4 years for Whites • Black Men- 68.3 years • White Men- 74.8 years • Black Women- 75 years • White Women- 80 years Between 1990 and 2001, black men’s life expectancy increased by nine years and black women increased by 5 years. Whites increased too by ½ as much
Disparities in Educational Funding • New York School districts serving poorer and minority neighborhoods receive $2152 less per student compared to school districts with fewer poor students • An average elementary school may have 400 students translating into a massive $860,800 difference • Lack of funding leads to lack of teachers, books, education…. The Funding Gap: Low- Income and Minority Students Receive Fewer Dollars by the Educational Trust 2002
Access to Medical Care • There are two million New Yorkers without health insurance • Poorer New Yorkers without health coverage are the most likely to not receive medical care. • However even those with private health insurance or Medicare continue to have racial/ethnic disparities in health. • “Race and income have substantial effects on mortality and use of services among Medicare beneficiaries. Medicare coverage alone is not sufficient to promote effective patterns of use by all beneficiaries “ Marian E. Gornick, M.S., Paul W. Eggers, Ph.D., Thomas W. Reilly, Ph.D., Renee M. Mentnech, M.S., Leslye K. Fitterman, Ph.D., Lawrence E. Kucken, M.P.A., and Bruce C. Vladeck, Ph.D. NEJM Vol 335:791-799, No. 11, 8/12/96
Pt Esmin Green Ignored to Death in NY Hospital Emergency Room HHC President Alan D. Aviles said in a statement "It is clear that some of our employees failed to act based on our compassionate standards of care." NYCLU Executive Director Donna Lieberman said at the time "The pattern of neglect and abuse at Kings County Hospital Center is an affront to human dignity,". “There over 80,000 black patients like Esmin Green that die prematurely every year across the US due to healthcare disparities and lack of cultural competency.“ How many more deaths will be needed to enact statewide healthcare reform?
Shortage of Primary Care Physicians in Minority Neighborhoods In 2004 there were 74 primary care physicians per 100,000 people in the bottom sixth neighborhoods of health outcomes This is compared to 197 primary care physicians per 100,000 people in the top sixth neighborhoods of health outcomes.
MUTUAL RESPECT We must all respect each other to prevent the atrocities and excess deaths from racism and discrimination
Improve Education byReforming the Classroom • Smaller class size enables more learning • Provide behavior consultants for those children in need • Comprehensive students assessments for those having difficulty • Improve teacher training • Tie teacher benefits to academic improvement in test scores • Preparation for employment and good health starts in kindergarten
Improve Education Improve educational protocols in the zip codes with the highest health disparities: Rationale: Schools like the Harlem Village Academy Charter School should be a model for all NYC public school education. They have taken 5th graders performing in the bottom 25% of test scores and turn them around by the time they enter 7th grade to be in the top 5% of test scores city wide. They have a rigorous curriculum grounded in the highest expectations for all students. A caring and nurturing environment. They teach students to think deeply, independently, and critically. They have a longer school day from 7:30 am to 5:30pm with Saturday school and study hall for students whom need extra help and attention. They have a culture of accountability for academic achievement, a clear strict code of conduct that is consistent throughout the school and school uniforms that contribute to a culture of respect, scholarship, and community.
HIGHER EDUCATION ALMOST ELIMINATES THE RACIAL UNEMPLOYMENT GAP • Blacks armed with a four-year college diploma not only are far less likely to be unemployed, but the black-white unemployment gap is greatly reduced. • Employment leads to reduced poverty and greater access to healthcare. • Therefore, the historical two-to-one racial unemployment gap is reduced to 1.25-to-one for those with a college diploma. “US Labor Department, June 2004”
Improve Self Esteem of Youth and educate about AcademicBlack Heroes Improve the self-esteem of Black youth and educate all youth about the truthful significant historical contributions by Blacks to society today. The current educational system fails to teach the truth about history specifically the original contributions to civilization, science and technology by Africans via Ethiopia, Egypt, the Black Pharaohs contributions by the building of the pyramids. The first great physician Imhotep was an African physician. The teaching of the accomplishments of Blacks both ancient and modern in the New York City public school system would improve the self-esteem to Blacks to achieve and strive to become the future Black or American Heroes.
We need to Train More Black and Black Hispanic Physicians • More minority health care providers are needed especially since they are more likely to serve in minority and medically underserved communities
Must Support Health Pipeline Recruitment/Development *Support Reading Programs Encourage all students to carry a book and read 1-2 hours a day. Stop the notion in the Black community that reading is acting white, this is a concept that is still prevalent from slavery in many black communities. Support Mentoring programs Support educational summer programs and afterschool programs (www.snma.org) (www.nyesma.org)
Improve Health Literacy and Break Language Barriers • More interpreters to overcome language barriers • Grassroots community based health workers to help patient navigate and access the health care system • Provide understandable patient education programs and materials to increase patients knowledge of how to access care • For patients whom cannot read, we must communicate effectively to our patients
Educate individuals about Personal Responsibility • Increase physical activity • Walking, running, athletics, swimming • Expand physical education requirement in schools at least 3x/week • Health diet • Increase water intake, vegetables, fruit, lean chicken and fish • Avoid high caloric fats, red meats, starches, soda, juices • Healthier behavior • Avoid premarital/unprotected sex, smoking, drinking, substance abuse Reduce Stress
Must Stop & Prevent Tobacco Use • Most preventable cause of death in our society accounting for 30% of all cancer deaths • Causes nearly 87% of all lung cancers • People who quit before the age of 50 cut their risk of dying in the next 15 years in half • A Major Cause of Cardiovascular disease • 80% of smokers begin to smoke before the age of 18
If crime is down 30% why is incarceration up? There is racial bias at every stage of the criminal justice system including policing, arrests, sentencing and parole. In Suffolk County Blacks make up 7% of the population but 40% of the jail population. In Rensselaer County Blacks make up 5% of the population but 35% of the jail population. We MUST STOP DISCRIMINATION, The statistics are not a result of more criminal behavior in the Black community We must Stop the State Commission of Corrections from mandating the construction of correctional facilities in NYS We must institute contract controls to monitor how contracts are distributed and their impacts on taxpayers
Prevent the Incarceration of Black Men • Education • Community Centers • After school programs • Provide comprehensive behavior intervention for those whom may be in need • Re-educate and provide job training and transition programs to those incarcerated and to be released • Provide mental health to those in need • Stop racial discrimination I policing and stop arrest quotas
Bring Divert Court model from Dallas Texas to NY to reduce incarceration Established 10 years ago Divert Court has been shown to have a tremendous cost/benefit savings. On average, for every $1 spent on upgrading drug treatment and diverting offenders from traditional incarceration, to drug treatment through DIVERT Court, $9.43 of costs can be saved by society over a 40 month post-treatment period. Emphasis is place on rehab and treatment and avoiding incarceration WHAT A RETURN ON INVESTMENT!!!!!!!
Alternative to Jail Construction Creating Pre-Arrest Programs, Citation programs to avoid initial booking Programs for the mentally ill Improve release procedures and the pretrial and sentenced populations Specialty courts, drug court, mental health court, domestic violence court Alternative punishment to incarceration including expanding probation All suggestions will save NYS taxpayer millions of dollars
Youth Conflict resolutionand Legal Education Create violence reduction, conflict resolution, and preventive law education protocols for junior high school students and public: Rationale: This will help reduce prevent incarceration. The state does not allow religion to be taught in schools. Thus there is a void in the teaching of morals and principles of right and wrong. Children coming from poorer families often have parents away from the home working 2 and 3 jobs to make ends meet and maybe deprived of this nurturing. The educational system must participate in educating students about the consequences of criminal activity. We must also have funding for research identifying the most common zip codes with incarcerated minority youth, and identifying the reasons for incarceration and create programs to prevent this adverse outcome in those specific zip codes.
NYC “Take Care New York” • Have a regular doctor • Be tobacco free • Keep your heart healthy (control weight, Cholesterol, BP) • Know your HIV status • Get help for depression • Live free of dependence on alcohol and drugs • Get checked for cancer • Get the immunizations you need • Make your home safe and healthy from lead • Have a healthy baby, obtain prenatal care NYC Department of Health and Mental Hygiene
Empire State Medical AssociationRecommendations toaddress healthcare disparities
Cultural Competency Legislation must be enacted to ensure Mandatory Cultural Competency for all Physicians and Healthcare Workers in New York State. All licensed healthcare workers in New York must be made aware of the terminal effects of prejudice in healthcare on ethnic minority groups in New York State. David Satcher M.D. the former U.S. Surgeon General estimates there are over 83,570 annual premature deaths due to prejudice in healthcare. Dr. Nelson Adams the 111th President of the National Medical Association states: "Cultural competency education is urgently needed, racial inequities in healthcare will never be scientifically justified, politically excusable, and never morally acceptable".