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HEALTH DISPARITIES Researchers Chronicle Unequal, Race-based Health CareBlack adults receive worse medical care than whites across a range of health quality measures according to an HSPH study in the March 13 Journal of the American Medical Association, which involves Medicare enrollees in managed care plans. Two weeks earlier, the Massachusetts public health department reported that black babies of Boston parents died at a rate more than four times higher than white infants. While black infant mortality rose, the overall infant mortality rate fell to the lowest level in the state's history.
Relying, in part, on a personal library of more than 5,000 books and documents, Linda Clayton (left) and Michael Byrd hope to inspire change with An American Health Dilemma, their two-volume chronicle of 2,500 years of scientific and medical racism. Photo by Graham Ramsay Week by week, study after study tells a troubling story about racial differences in sickness and health. In nearly all statistical comparisons, the losing score goes to African Americans, although the death and disease numbers for Native Americans and Hispanic Americans also show a similar gap against the comparatively robust health of European Americans. The Institute of Medicine weighed in with another report on the issue, on March 20. It has become commonplace for blacks in the U.S. to top the charts every year in most of the 10 leading causes of death, says a new book by two faculty members at HSPH, both researchers in the Division of Public Health Practice. In the second of a two-volume set, the authors and obstetrician-gynecologists Michael Byrd and Linda Clayton continue a 2,500-year chronicle of the roots of today's entrenched race- and class-based health disparities. The most recent volume focuses on the last century. "We make a fairly good case for how deeply ingrained the disparities are and that we're all acting as if that is normal and legitimate," Byrd said. "We can't continue to do business as usual." The title, An American Health Dilemma: Race, Medicine and Health Care in the United States 1900-2000, echoes an influential 1944 book on race and democracy in America. In both titles, the "American dilemma" refers to the moral contradiction of a nation torn between allegiance to its highest ideals of universal equality and justice and awareness of the base realities of racial discrimination. "Most of us know bits and pieces of it, but when they put it all together there is a power in the validity and a magnitude in the cumulative impact," said orthopedic spine surgeon Augustus White, the Ellen and Melvin Gordon professor of medical education at Beth Israel Deaconess Medical Center and master of the Holmes Society at HMS. "It isn't written in protest. It's not propaganda. These are the facts, and we have to face them." Established RacismLike many researchers, Byrd and Clayton began their encyclopedic quest with questions informed by clinical observation and personal experience. Both grew up in relatively affluent middle-class black families in the segregated South.In their medical training and careers, they lived close to the history documented in their book. Like 80 percent of black physicians for most of the century, Byrd graduated from a traditionally black medical college, Meharry Medical College in Nashville. In his clinical rotations through John Andrew Hospital, he met some of the scientific leaders of the Tuskegee syphilis experiment at the height of the Civil Rights era. As a student indoctrinated into the unconscious racism of the U.S. public health and medical establishment, he did not question the protocol. Typical of many other black physicians, Byrd devoted himself to a largely African-American and poor, urban patient population during the 1970s and '80s, when hospitals commonly denied privileges to minority physicians in hopes of excluding their poor, black, and Latino patients. He witnessed involuntary sterilizations on black and poor patients. Clayton, meanwhile, graduated from Duke Medical School, a place that would not have admitted her pregnant mother 25 years earlier for Clayton's birth. In her obstetrics-gynecology medical school class, she remembers the lecturer described black women as promiscuous and therefore prone to cervical cancer. Clayton was the only black and the only woman. She challenged her professor, "Where is the evidence?" Clayton and Byrd met when he returned to practice and teach at Meharry, where Clayton was head of the gynecologic oncology division. They soon became collaborators on projects and papers addressing racial disparity. They eventually moved to Boston, where they earned master's degrees from HSPH 10 years ago. Speaking VolumesThe first volume of their work, published last year, reviewed the medical and public health history of African Americans and the problem of race from antiquity to 1900, when many scientists were still intent on proving inferiority by skin color, hair texture, nose width, and lip thickness."The stubborn persistence of the race- and class-based health system conundrum can be explained [by] a medical-social culture hundreds of years old that is heavily laden and burdened by race and class problems compounding continued social and economic deprivation," they write. An example of the type of research they are counting on to begin to correct the inequities is the March 13 JAMA paper on Medicare managed care. HSPH researcher and lead author Eric Schneider, an internist at Brigham and Women's Hospital, and colleagues found that racial disparities in four measures of care quality might be due, in part, to disproportional numbers of African Americans in poorly performing Medicare managed care plans but that the disparities were also present in most health plans. The Institute of Medicine's March 20 report acknowledges the problem in its title--"Unequal Treatment"--and lays a foundation for further research and interventions. Byrd served on the IOM committee that issued the report. Byrd, Clayton, White and others are developing dedicated cross-cultural curricula for medical students, residents, researchers, and physicians aimed at raising awareness and, ultimately, eliminating these insidious health inequities. --Carol Cruzan Morton |
