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Why Racial Disparities Are Alive And Well In Healthcare

It was 1999 when the Federal government first acknowledged our nation had a problem with race and health care. That year, Congress tasked the Institute of Medicine to study the matter, and the resulting report was not good. Minorities were in poor health and receiving inferior care, the report said. They were less likely to receive bypass surgery, kidney transplants and dialysis. If they had diabetes, they were more likely to undergo amputations, meaning their disease had been poorly controlled. And there was a lot more where that came from.

unequal2 201x300 Racial Disparities in Health Care: The Hundred Years WarThe IOM report was a call to action. In subsequent years, lawmakers crafted policies and established goals for improvement. Federal and state governments and numerous foundations set aside billions to fund projects. Health services researchers expanded their efforts to study the problem.

Twelve years later, we have something to show for the effort. Steep declines in the prevalence of cigarette smoking among African Americans have narrowed the gap in lung cancer death rates between them and whites, for example. Inner city kids have better food choices at school. The 3-decade rise in obesity rates, steepest among minorities, has leveled off.

Nevertheless, racial disparities persist across the widest possible range of health services and disease states in our country. The overall death rate from cancer is 24% higher for African-Americans than white people. The racial gap in colorectal cancer mortality has widened since the 1980s. African Americans with diabetes experienced declines in recommended foot, eye, and blood glucose testing between 2002-2007. Read more »

*This blog post was originally published at Pizaazz*

Weight-Loss Counseling: Is Race A Factor?

Most people know that the U.S. is struggling to contain a surging epidemic of obesity, and that the problem is most acute among African-Americans. Whereas about 27 percent of all adult Americans are obese (defined as having a body mass index of 30 or more), fully 37 percent of African-American adults are obese, and that number jumps to an appalling 42 percent among African-American women.

Over the years, public health officials have provided evidence that socioeconomic and cultural factors drive this racial disparity. Now, a new study suggests there is another reason as well: Obese African-Americans receive less obesity-related counseling than their white counterparts, and it matters not whether the physicians they see are African-American or white.

To reach these conclusions, Sara Bleich and colleagues from the Johns Hopkins School of Public Health used clinical encounter data from the 2005–2007 National Ambulatory Medical Care Surveys (NAMCS). The sample included 2,231 visits involving African-American and white obese people who were at least 20 years old and who visited family practitioners and internists that were either African-American or white. Asian and Hispanic patients and physicians were excluded from the study because their numbers were too small to permit hypothesis testing.

For each encounter in the study, the scientists determined whether the patient received guidance on weight reduction, diet and nutrition, or exercise from his or her physician. Read more »

*This blog post was originally published at Pizaazz*

Healthcare Disparities: The View From Harlem, NYC – Part 2

Stroke is the leading cause of adult disability in the United States and the third leading cause of death. Worldwide, stroke is the second leading cause of death. Like heart disease and cancer, serious stroke disparities persist in America. African Americans have a relative risk of stroke death that is 4 times higher that whites at ages 35-54, 3 times higher at ages 55-64, and 2 times higher at ages 65-74.

The reasons for this are the focus of my two blog posts.

Over the last decade, most of the research dollars spent on stroke has focused on treatment and recovery. Researchers have spent millions trying to come up with new blockbuster treatments that reduce stroke burden or reverse it’s disabling impact. Therapeutic clot-busters have emerged with narrow time-windows within which they must be administered. Relaxing these time constraints have been the subject of even more research, and stroke recovery laboratories explore brain re-learning, neuronal plasticity, and cellular regeneration.

While I believe that we must continue to remain leaders of new and innovative treatments of disease, there is no doubt in my mind that the best return for our healthcare dollars is prevention. It is the only thing that can reign in the runaway disparities in healthcare and reduce the physical and economic burden of disease among all Americans.

But prevention is complex. It is much more challenging than administering a clot-buster or taking a cholesterol-lowering drug. Prevention involves the entire community – the whole ecosystem. It involves the child or individual, his parents and grandparents, his schoolteachers, his neighborhood stores and local parks, his local government policies, his primary care physician, his local community clinic or hospital, his employment status, his wallet, and lastly, his genes. Compare this to treatment, which involves having access to particular medical interventions such as a drug or surgical procedure.

Stroke prevention can be subdivided into primordial prevention (preventing stroke risk factors like high blood pressure, diabetes, and obesity, from developing in the first place through healthy living), primary prevention (preventing a first stroke by treating identified modifiable risk factors like high blood pressure etc), and secondary prevention (preventing a second stroke from occurring by controlling risk factors and administering specific treatments like taking a daily aspirin or having surgery to open up clogged arteries in the neck).

For the purposes of this post, I will focus on primordial prevention. To begin, I will re-introduce the root causes of disparities outlined previously:

  • Educational status
  • Employment status
  • Insurance status
  • Income level

How do these factors influence primordial prevention? How do they interact to define ecological conditions within a specific community? How did they contribute to the young boy’s adolescent stroke? To begin, I will list factors endemic to the young boy’s environment:

1] Low Health Literacy – the “hidden dragon” of all treatable risk factors; so often underestimated and so dangerous to the beholder.

2] Unacceptable numbers of uninsured – the “crouching tiger” threatening to tear down the entire health system

3] Poor access to care – an unforgiving predicament.

4] Limited access to healthy and inexpensive food

5] Ubiquitous access to unhealthy and cheap food

6] Low levels of non-occupational physical activity or leisure-related exercise

7] High tobacco and alcohol consumption.

8] Chronic persistent stress levels that overwhelm coping mechanisms.

In a study by Mauricio Avendano and Maria Glymour, wealth and income levels were shown to be independent risk factors for stroke. Another study by Glymour, Avendano, Haas, and Berkman showed that childhood social conditions (southern state of birth, parental Socio-Economic Status or SES, self-reported fair/poor childhood health, and attained height) predicted stroke risk in black and white adults. Moreover, adjustment for adult SES, in particular wealth, nearly eliminated all the disparity in stroke risk between black and white subjects

The ecological conditions that shaped the young boy’s physical and limbic traits are examples of an uneven playing field. He was born into it – just like I was born into my little world. The sporadic binging on cheap ubiquitous fast food whenever his mom had a little money and the absence of playtime ultimately led to his childhood obesity. The complex conditioning of his limbic needs led to a psychological fragility that was encased by a shell of defensive behavior that in-turn caused truancy.  Substance abuse was around the corner waiting patiently for him. By age 15, the young boy was already a user; with open arms he was welcomed into “the hustle”. Mom was broken. One could see it in her eyes. She no longer worked. She no longer cared.  That is, until her son had a stroke when he was just 17-years-old – the day the drought ended, and she cried.

It was a hemorrhagic stroke. The high blood pressure in his brain arteries caused by accelerated atherosclerosis – the consequence of his substance abuse (tobacco, alcohol, cocaine), type-two diabetes, and undiagnosed hypertension – was what caused the stroke. The stroke was so large that it shifted half of his brain across the midline of his skull, crushing it against the inner-table on the other side.  Fortunately (some would say), the kid survived. Unfortunately, he wanted to die – 17-years-old and nursing home bound, unable to speak or swallow or move his right side.

The stroke was the final blow dealt by a cascade of disparities all too common in America.

Latest Interviews

IDEA Labs: Medical Students Take The Lead In Healthcare Innovation

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How To Be A Successful Patient: Young Doctors Offer Some Advice

I am proud to be a part of the American Resident Project an initiative that promotes the writing of medical students residents and new physicians as they explore ideas for transforming American health care delivery. I recently had the opportunity to interview three of the writing fellows about how to…

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Latest Book Reviews

Book Review: Is Empathy Learned By Faking It Till It’s Real?

I m often asked to do book reviews on my blog and I rarely agree to them. This is because it takes me a long time to read a book and then if I don t enjoy it I figure the author would rather me remain silent than publish my…

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The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

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Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

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