cultural and racial inequality in health care

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1 Memorandum To: TBD From: Jetmir Troshani Date: Date goes here Re: Cultural and Racial inequality in Health Care Outline: 1. Executive summary; 2. Overview; 3. Discussion; 4. Recommendations; 5. Conclusions. Executive summary Overwhelming facts reveals that racial and cultural minority groups are more likely to receive poorer quality health care than white Americans, even when factors such as insurance status are controlled” (American College of Physicians 2010). As the country’s population continues to grow and diversify, the health care system will have to change and adjust to meet the needs of an increasingly multicultural patient base. The statistical and anecdotal facts of racial injustice in American healthcare are undeniable. Studies done since 2003 by ACP shows systemic in addition to clinical discrimination, health practitioners, legislators, and normal citizens can no longer ignore the fact that America focuses on the color of one’s skin and the national origin of one’s ancestors still largely determine the quality of health care a consumer receives (American College of Physicians 2008; Urban Institute (2005). America thought that the issue of racial injustice and inequity was long gone, but it is shocking that the vice still endures largely, not only in the common platforms, politics and socials, but in a more critical issue like health care. After controlling the differences among the races in socioeconomic status, health insurance, access to

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Page 1: Cultural and racial inequality in Health Care

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Memorandum

To: TBD From: Jetmir Troshani Date: Date goes here

Re: Cultural and Racial inequality in Health Care

Outline:

1. Executive summary; 2. Overview; 3. Discussion; 4. Recommendations; 5. Conclusions.

Executive summary

“Overwhelming facts reveals that racial and cultural minority groups are more

likely to receive poorer quality health care than white Americans, even when factors

such as insurance status are controlled” (American College of Physicians 2010). As

the country’s population continues to grow and diversify, the health care system will

have to change and adjust to meet the needs of an increasingly multicultural patient

base. The statistical and anecdotal facts of racial injustice in American healthcare

are undeniable. Studies done since 2003 by ACP shows systemic in addition to

clinical discrimination, health practitioners, legislators, and normal citizens can no

longer ignore the fact that America focuses on the color of one’s skin and the

national origin of one’s ancestors still largely determine the quality of health care a

consumer receives (American College of Physicians 2008; Urban Institute (2005).

America thought that the issue of racial injustice and inequity was long gone,

but it is shocking that the vice still endures largely, not only in the common platforms,

politics and socials, but in a more critical issue like health care. After controlling the

differences among the races in socioeconomic status, health insurance, access to

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health care and geographic differences, the statistical facts still demonstrates that

Blacks and Latinos still get lesser and substandard medical attention than their

counterparts, the whites, irrespective of whether those services are for treatment of

cardiovascular disease, chronic diseases, mental illness, child medical care or

HIV/AIDS.

Comparing these minority groupings (African Americans, Native Americans,

Asian Americans, and Latinos) with the white Americans, they are more vulnerable

to chronic illnesses, higher mortality rates, and worst health effects (Bardach 2009).

Among the disease-specific examples of racial and ethnic disparities in the U.S. is

the cancer incidence rate among Blacks that is 10 percent more than among the

white Americans (Barrett, Dyer and Westpheling 2008; Kettl 2007). Also, adult

Blacks and Latinos are almost twice more than Whites prone to diabetic

complications. Although African Americans, Latinos and Native Americans suffer and

succumb to diabetes more often than then whites, research show the disease is not

well handled among minorities.

Paradoxically, Black, Native and Hispanic Americans have more medical

attention services than do whites for those undesirable medical attentions, for

instance amputations, and cesarean section among others. Although these are

necessary attentions, they are considered undesirable because a patient would

rather avoid them if at all they had an option, for instance many patients would prefer

to keep a leg if it could be made healthy, rather than going for an amputation.

Undisputedly, ignoring these injustices would take the efforts of social scientists,

researchers, health care providers, legislators, environmentalists, clergy, and

patients among others to adequately attend to the matter (Lurie and Dubowitz 2007;

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Schlotthauer et al. 2008; Zuckerman et al. 2008). Although the issue is multi-sided,

this paper looks at the policy solutions available.

Overview/Background

Lexically, health inequalities refer to the gap in the quality and accessibility of

medical attention among racial, ethnic, socio-economic groupings. Almost as long as

there have been hospitals in America, there have been racial disparities in the health

care system. The first hospital founded in the U.S. was the Pennsylvania General

Hospital, established in Philadelphia in 1751 from private funds, donated for the care

of the less-fortunate and the mentally unstable. In the beginning of its operations,

records from Pennsylvania General did not show that any patients other than whites

were admitted for care. The institution was, in fact called the “First Anglo Hospital”1

in the U.S. nevertheless, historical records reveals that the institution eventually

began to admit non-Caucasian patients. Beginning in 1825 and 1829 respectively,

Pennsylvania General began to record the “color” and “national origin” of admitted

patients, confirming that the hospital at some point began offering services to both

Black and white patients (Baker et al. 1996).

In fact, before end of slavery in America, the judicial record reveals that

African-Americans got a significant healthcare whenever need be; their health

influenced their monetary value as property of slave-owners. After the Civil War,

giving access to African Americans took on a different dimension. Waves of Blacks

migrating from the south began to mount pressure on health care amenities to serve

Black and white patients the same. During the Reconstruction, racial segregation,

surfaced both within healthcare institution used by both the non-native American and

1 More reading from Grumbach, K. and Mendoza, R. (2008) and American College of Physicians. (2006).

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white patients, professional, and physicians, and in the structure of the hospital

industry itself. Martin Luther King, Jr. quotes that “Of all the forms of inequality,

injustice in healthcare is the most shocking and inhumane” (as cited in ACP 2004).

Ever since overt racial disparities has grown and still looms.

Arguably, health disparity starts shortly after conception. One pointer of a

child's healthy birth, making other lifetime outcomes more probable to be successful,

is whether mothers get early medical care at pregnancy. 25% of African-American

women do not receive prenatal attention at the first trimester, while 11% of white

women get none (American College of Physicians 2007; Bach et al. 2004; Dorn et al.

2008). For African-American women, 6% do not receive prenatal attention, but only

2% of white women, one third the number of 27 blacks, get no or too-late care.

Considering infant mortality during the first year of life, there are 14 deaths for

African-American and six for native Americans/1,000 live births. However, proper

prenatal care likely could have prevented some of these deaths. Infant mortality and

morbidity are enduring, thus the high rate of African-American infant mortality shows

the probability of a similarly higher rate of black infants who survive with unhealthy

conditions that make school and lifetime success more difficult. It is these disparities

in pregnancy and childbirth, which are eventually reflected in racial inequality

(Winkleby et al. 1992).

Discussion

Inequality of access to health care in the adequacy of care different cultural

and racial groups get can include:

Difficulties with patient-practitioner communication. In delivering medical care,

communication is essential so as to administer proper and effectual treatment

and attention in disregard to racial group. As miscommunication could lead to

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inaccurate analysis, wrong medication, and failure to get a follow-up attention.

As Flores (2007) describes, “Cross-cultural differences in information-seeking

patterns, communication styles, perceptions of health risk, and ideas about

prevention of disease [have] an impact on health.” In the US language barrier

is even worse, especially among the non-natives groups. Statistically, “less

than half of non-English speakers who say they need an interpreter during

health care visits report having one. In addition, communication barriers crop

up from the lack of cultural understanding on the part of white providers for

their minority patients” (Halbert et al. 2006).

Practitioner inequity. In some cases the medical care practitioners either

unconsciously or consciously attends to some racial patients in a different way

than other patients. Some studies show that racial minority patients are “less

likely than whites to receive a kidney transplant once on dialysis. Critics argue

that certain diseases cluster by ethnicity and that clinical decision making

does not always reflect these differences” (Institute of Medicine 2004).

Lack of preventive care. According to the 2009 National Healthcare

Disparities Report, “uninsured Americans are less likely to receive preventive

services in health care, for instance racial minorities are not regularly

screened for colon cancer and the death rate for colon cancer has increased

among African Americans and Hispanic people”2.

“Many people of colored skin are facing poor health care than whites from the

cradle to the grave, in terms of greater rates of infant mortality, chronic diseases and

disability, and pre-mature death” (Peterson and Yancy 2009). These health

2 As cited in U.S. Department of Health and Human Services Office of Disease Prevention and Health

Promotion (2007).

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disparities take a significant human toll, but in addition inflict a huge economic weight

on America. A recent research conducted shows that the direct health costs, that is,

related with health inequalities, extra costs of medical services incurred due to the

greater burden of diseases suffered by the minority groups-was more than US$250B

in the period between 2003 and 2006. Aggregating the indirect costs related with

health inequalities, for instance foregone salaries and yield and foregone tax

revenue, the total costs of health inequalities for the country was US$1.24B in the

same duration (Kettl and Fesler, 2009).

With the inception of Obama administration, things are looking bright. With the

enactment of the Health Reform Law, this will see more than 32 million uninsured

Americans, the majority being the minorities get insurance coverage. These laws will

avert insurance companies from exploiting new enrollees and rejecting claims due to

the earlier conditions and more medical care providers will get more incentives to

work in “medically underserved communities, among other expected benefits. These

legislations will improve the current state of health care for people of colour, who are

disproportionately un- and under-insured and who face greater barriers than whites

to receiving high-quality care, even when insured” (Herbert et al. 2008). A research

commissioned by the Institute of Medicine (2002) estimated that: “over 886,000

deaths could have been prevented from 1991 to 2000 if African Americans had

received the same care as whites. The main differences were due to lack of

insurance, inadequate insurance, and poor service for the minority patients.”

Recommendations

Youdelman (2007) and Smedley (2008) argue that “The correlation between

socioeconomic position and health, is a pervasive correlation, which is seen across

periods of time, across places in the world, and across groups… and it is almost

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invariably in the same direction,” as socioeconomic position increases, health

improves. Youdelman opines that although there are various means to explain health

inequalities (from a racial and ethnical dimension, socio-economics, and geography)

socioeconomic inequalities should take center stage in the health policy talk,

because application of some policy functions can worsen this issue.

However, according to Schillinger et al. (2003) ‘race is not an issue’ when it

comes to matters of health inequity. He notes that the income differences across

racial groups, exposure to social and economic adversity over the time and

subjection to prejudice and institutional bigotry can influence the health of the

minorities in several ways. Schillinger et al. (2003) “underscores this by revealing

that majority of the socio-economic group of black women have almost or even

higher rates of infant mortality, low birth-weight, hypertension and obesity than the

lowest socioeconomic group of white women.” Blendon et al. (2008) emphasize on

the use of specific approaches to contain racial disparities and urges that the health

policy should be redefined so as to take account other sectors of the community,

which have health impacts.

It is noticeable that the minority groups face distinctive and intricate

challenges in modern policy environment, from crisis alertness and response to

equal access to proper medical attention. Recognizing the situation, those

representing these groups should join forces and put forward a strong voice in

addressing these intricate (Williams and Jackson 2005).

To reduce the health inequalities, more emphasis should be made on

evidence-based techniques modeled to overcome the groups struggle against

medical and public health research, together with:

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Result-orientation: research entrenched in a community background modeled

to achieve substantial outcomes and attain the optimal performance.

Community collaboration: partnering “with” the groups, instead of giving things

“to” them;

Ethnical tolerance: models custom-made for community demands and

reaches;

Notably, equity of access to quality health care cannot be guaranteed

through uniformity in a multicultural community, but through cultural sensitivity in

delivery of medical care is equally necessary in achieving this equality. In

ascertaining cultural tolerance, we should find if the current delivery of health care is

impartial, and if it is as it is, then know how to reverse the situation. A more

practically approach in dealing with this is “ethnic match”3 which seems to have a

remarkable effect on the patients and providers in terms of access and utilization of

health care services. In America, Barrett, Dyer and Westpheling (2008) observe that

the more the minorities’ workers working in a mental institution, the higher the

utilization rate by the minorities. Moreover, many surveys have revealed that an

“ethnic match” between patient and the practitioner normally increase utilization rate

while reducing the dropout rate. However, in addressing such inequalities numerous

viable options have been raised. These options range from simple and realistic to

involving a whole change to the system. Blanton et al (2002) notes “improvements in

quality of care can simply begin with multilingual information, link workers,

appropriate diets to a multi-faith approach in hospital.” While on the other hand, U.S.

Department of Health and Human Services Office of Disease Prevention and Health

3 See more discussion on “ethnic match” by Barret, S. R. et al. (2008). Health Literacy Practices in Primary Care Settings: Examples from the Field. Washington, DC: The Commonwealth Fund.

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Promotion (2008) advocates for “anti-racism service delivery” which involves

“ensuring that providers are reflective of ethno-racial communities and

knowledgeable about issues of race, gender, power and privilege, that people of

color are involved in planning, implementing and evaluating these services and that

services are appropriate to the needs of communities of color”4.

However, the provisions made on the health reform law do not assure an

answer the health care inequalities issue, as going by studies having health

insurance doesn’t assure access to quality medical services neither does it

considerably better health services. Instead, it is notable that health disparities

continue due to differences in the neighbourhoods of the minority and non-minority

groups. Racial and cultural minority groups are more probable than white Americans

to live in segregated, poverty-ridden populations, people who have ever since

experienced lack of health care resources (Zuvekas and Taliaferro, 2003). Even

worse, majority of these people stare at a host of health dangers, for instance a lot of

environmental stressors, and an influx fast food outlets and liquor shops and have

rather countable health-conscious investments, for instance grocery outlets. One’s

environment has a considerable effect on his/her general health status. 25% of

preventable diseases globally are associated to poor environmental quality.

Reschovsky and O’Malley (2008) recommend that “The government at all levels can

improve health opportunities by stimulating public and private investment to help

make all communities healthier. It can achieve this by providing incentives to

improve neighbourhood food options, by aggressively addressing environmental

degradation, and by de-concentrating poverty from inner-cities and rural areas

through smart housing and transportation policy.” Many of these strategies are highly

4 Also cited by Kaiser Family Foundation (2006).

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cost-effective; however addressing health inequities that are the outcome of

environmental stressors can be a complex and challenging task. Moreover,

policymakers should come up with a set of measures to track environmental

stressors and how they impact on the health inequities of racial and cultural minority

groups (Gaskin et al. (2007).

According to the American College of Physicians, although America has made

some tremendous advances towards achieving health care equality, a lot still needs

to be done. "Closing the disparity gap is not only morally and professional

imperative, it remains a glaring civil rights injustice that must be addressed," the ACP

(2010) says. Improved communication is one of the core issues in bridging the

inequality gulf in a country where approximately a quarter of the inhabitants are not

native English speakers. Also, given that by the year 2042, according to the U.S.

Census Bureau, “half of America’s population will be people of colour, it is imperative

that we be prepared to address the health needs of an increasingly diverse

population”5. It is also recommended that all third‐party payers, such as Medicare,

pay for the services of interpreters, and “language services”. In addition, medical

professionals should be trained to have racial and ethnical tolerance so they

appreciate the medical care practices and misunderstandings harboured by racial

and ethnic minority groups (Hoffman and Tolbert 2006).

“Organizations that set standards for medical education”, the ACP (2010)

reports, “are becoming believers in this kind of training — an encouraging sign of

progress. To create a more diverse physician workforce, we should strengthen the

5 Cited by James, C. et al. (2009). Putting Women’s Health Care Disparities on the Map: Examining Racial and Ethnic Disparities at the State Level. Kaiser Family Foundation. Retrieved from http://www.kff.org/minorityhealth/upload/7886.pdf

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education of minority students, especially in math and science, at all levels to create

a larger pool of qualified minority applicants for medical school.”

Similarly, medical schools should enrol and retain more minority faculty. One

nagging societal ills highlighted in the ACP report is the advertisement of tobacco

and alcoholic products, and fast foods to minority groups.

Conclusion

Racial and cultural inequities in health care emerge from the interaction of

many intricate factors, including past and current discrimination in health care,

genetics, unequal educational opportunity, income and health care access

disparities, cultural beliefs, and community systems. Bridging the disparity gulf is not

easy, but it is a moral imperative that appropriate resources should be made to

address these differences.

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