Racial discrimination has shaped so many American institutions that perhaps it should be no surprise that health care is among them. Put simply, people of color receive less care — and often worse care — than white Americans.
Reasonsincludes lower rates of health coverage; communication barriers; and racial stereotyping based on false beliefs.
Predictably, their health outcomes are worse than those of whites.
African-American patients tend to receive lower-quality health services, including for cancer, H.I.V., prenatal care and preventive care, vast research shows. They are also less likely to receive treatment for cardiovascular disease, and they are more likely to have unnecessary limb amputations.
As part of “The 1619 Project,” Evelynn Hammonds, a historian of science at Harvard, told Jeneen Interlandi of The New York Times: “There has never been any period in American history where the health of blacks was equal to that of whites. Disparity is built into the system.”
African-American men, in particular, have the worst health outcomes of any major demographic group. In part, research shows, this is a result of mistrust from a legacy of discrimination.
Tuskegee and lower life expectancy
At age 45, the life expectancy of black men is more than three years less than that of non-Hispanic Caucasian men. According to a study in the Quarterly Journal of Economics, part of the historical black-white mortality difference can be attributed to a 40-year experiment by the U.S. Public Health Service that shook African-Americans’ confidence in the nation’s health system.
From 1932 to 1972, the Public Health Service tracked about 600 hundred low-income African-American men in Tuskegee, Ala., about 400 of whom had syphilis. The stated purpose was to better understand the natural course of the disease. To do so, the men were lied to about the study and provided sham treatments. Many needlessly passed the disease on to family members, suffered and died.
As one scholar put it, the Tuskegee study “revealed more about the pathology of racism than it did about the pathology of syphilis.” In fact, the natural course of syphilis was already largely understood.
The study was publicized in 1972 and immediately halted. To this day, it is frequently cited as a driver of documented distrust in the health system by African-Americans. That distrust has helped compromise many public health efforts — including those to slow the spread of H.I.V., contain tuberculosis outbreaks and broaden provision of preventive care.
According to work by the economists Marcella Alsan and Marianne Wanamaker, black men are less likely than white men to seek health care and more likely to die at younger ages. Their analysis suggests that one-third of the black-white gap in male life expectancy in the immediate aftermath of the study could be attributed to the legacy of distrust connected to the Tuskegee study.
Their study relies on interpreting observational data, not a randomized trial, so there is room for skepticism about the specific findings and interpretation. Nevertheless, the findings are consistent with lots of other work that reveals African-Americans’ distrust of the health system, their receipt of less care, and their worse health outcomes.
The Tuskegee study is far from the only unjust treatment of nonwhite groups in health care. Thousands of nonwhite women have been sterilized without consent. For instance, between the 1930s and 1970s, one-third of Puerto Rican women of childbearing age were sterilized, many under coercion.
Likewise, in the 1960s and 1970s, thousands of Native American women were sterilized without consent, and a California eugenics law forced or coerced thousands of sterilizations of women (and men) of Mexican descent in the 20th century. (Thirty-two other states have had such laws, which were applied disproportionately to people of color.)
For decades, sickle cell disease, which mostly affects African-Americans, received less attention than other diseases, raising questions about the role of race in how medical research priorities are established.
Outside of research, routine medical practice continues to treat black and white patients differently. This has been documented in countless ways, including how practitioners view pain. Racial bias in health care and over-prescription of opioid painkillers accidentally spared some African-Americans from the level of mortality from opioid medications observed in white populations.
“While African-Americans may not have died at similar rates from opioid misuse, we can be sure needless suffering and, perhaps even death, occurred because provider racism prevented them from receiving appropriate care and pain medication,” said Linda Goler Blount, president and chief executive of the Black Women’s Health Imperative.
Black patients and black doctors
Of course, health outcomes are a result of much more than health care. The health of people of color is also unequal to that of whites because of differences in health behaviors, education and income, to name a few factors. But there is no doubt that the health system plays a role, too. Nor is there question that a history of discrimination and structural racism underlies racial differences in all these drivers of health.
Reinforcing the fact of racial bias in health care, a recent study found that care for black patients is better when they see black doctors. The study randomly assigned 1,300 African-Americans to black or nonblack primary care physicians. Those who saw black doctors received 34 percent more preventive services. One reason for this, supported by the study, is increased trust and communication.
The study findings are large. If all black men received the same increase in preventive services as those in the study (and received appropriate follow-up care), it would reduce the black-white cardiovascular mortality rate by 19 percent and shrink the total black-white male life expectancy gap by 8 percent, the researchers said.
But it is unlikely all black men could see black doctors even if they wished to. Although African-Americans make up 13 percent of the U.S. population, only 4 percent of current physicians — and less than 7 percent of recent medical school graduates — are black.
This study does not stand alone. A systematic review found that racially matched pairs of patients and doctors achieved better communication. Other studies found that many nonwhite patientsprefer practitioners who share their racial identity and that they receive better care from them. They view them as better than white physicians in communicating, providing respectful treatment and being available.
Racial bias in health care, as in other American institutions, is as old or older than the republic itself.
Title VI of the 1964 Civil Rights Act stipulates that neither race, color nor national origin may be used as a means of denying the “benefits of, or be subjected to discrimination under any program or activity receiving federal financial assistance.” As nearly every facet of the American health system receives federal financing and support, well-documented and present-day discrimination in health care suggests the law has not yet had its intended effect.
There’s a lot of media attention on a recent study examining whether labeling food with the amount of exercise that would be needed to then burn it off changes how much people eat. Let’s dig in and see.
The following originally appeared on The Upshot (copyright 2020, The New York Times Company).
Research has established that as much as a quarter of American health spending is waste.
There are two basic ways of tackling it, by focusing narrowly on specific types of patients or on the system as a whole. The patient-centered approach starts with this fact: A relatively small group of patients — 5 percent — account for half of all health spending.
It’s widely believed that making so-called super-utilizers even a little healthier — for example, giving them extra help once they’re out of the hospital to prevent a quick return there — would yield substantial savings. This idea, based on some weak evidence, has received considerable media attention and government support.
A rigorous study, published Wednesday, makes clear it’s not so easy. In fact, the study’s results are likely to be viewed by many as a major disappointment.Yet they also help guide us to what may be better strategies for cutting waste.
The study, published in the New England Journal of Medicine, was a big test of the people-focused approach: a randomized trial of a program in Camden, N.J., to reduce super-utilizer spending. About 800 very sick patients were randomly assigned into the program or to usual care. (The program has since expanded to other cities.)
To try to avoid a repeat hospitalization, the program provided an unusually large amount of care to very sick patients after they left the hospital, including from registered nurses, social workers, licensed practical nurses, community health workers and health coaches.
In the three months after a hospital stay, an average patient in the program received 7.6 home visits and 8.8 phone calls from staff. In addition, program staff went along on patients’ visits to physicians, which averaged 2.5 per person.
The result of all this effort?
For the six months after randomization, patients in the treatment and control groups had about the same chance of returning to the hospital, the same number of return hospital visits, the same amount of time spent in the hospital over all, and the same hospital costs. (It’s possible these measures differed across groups in small ways the study wasn’t large enough to detect.)
That doesn’t mean it’s impossible to reduce readmissions or health care spending of targeted patients. Some previousrandomized evaluations of other programs have found reductions in hospital readmissions of 15 percent to 45 percent, and in some cases reduced spending.
But it’s important to understand the difference between those studies and the Camden one.
“The Camden model targets a population that has a much more varied set of medical needs and social complexity, and with higher health care spending, than the existing successful models,” said Amy Finkelstein, a health economist at M.I.T. and a co-author of the Camden study.
The other approach to fighting wasteful medical spending starts with looking at health care as a system of goods and services: medications and surgical procedures, administrative processes and physical infrastructure. Some of these enhance health and others don’t, while some of it costs more than its benefits warrant. If you can identify wasteful goods and services and deliver effective care at lower prices, you can make the system more efficient for everyone.
One advantage of the systemic approach is that it’s easier to replicate than programs focused on super-utilizers. If eliminating or replacing a drug, procedure or administrative process means that spending at a hospital goes down, it’s relatively simple to adopt that change at other hospitals. But conceptually simple doesn’t mean easy in practice.
“Directly and systematically reducing wasteful care is hard because the most successful strategies threaten the revenue of dominant health care providers,” said Michael McWilliams, a professor at Harvard Medical School and a general internist with Brigham and Women’s Hospital. “One person’s waste is another’s income.”
This may be why big health systems are resistant to systemic change and prefer patient-focused approaches. Dr. McWilliams and Aaron Schwartz, a resident at Brigham and Women’s Hospital, wrote a commentary in the New England Journal of Medicine arguing in favor of a systems view of cost cutting. A focus only on the relatively few high spenders could miss a lot of waste, it said. Even though the rest of the population may use less care than super-utilizers, collectively they could account for as much or more waste.
The people-focused approach, on the other hand, is more likely to improve some patients’ experience because it involves additional preventive care.This could manifest itself as less pain or anxiety, and more “satisfaction” with care. But saving money this way requires accurate predictions of who is likelier to use a disproportionately large amount of health care. We don’t yet know how to reliably do this for enough people to make the approach efficient.
“The prevention myth is that it necessarily saves money,” said Sherry Glied, a health economist and dean and professor at the Wagner School of Public Service at N.Y.U. “Usually you need to provide preventive services to many people to avoid one bad outcome, and that makes it more expensive over all, even if it is better care.”
In a commentary on the Health Affairs blog, she also points out that high-cost patients are not all alike. They require different mixes of services to avoid costly outcomes. That calls for a lot of fine-tuning, which itself costs money and poses coordination challenges. It’s also harder to replicate.
The Camden study, unfortunately, did not measure patient experience, which might have improved. If patients did better in some ways and at no statistically significant additional cost, that could make its efforts worthwhile, even cost-effective.
That’s what an exclusive focus on reducing spending misses. The answer isn’t necessarily to pick a patient- or system-focused approach to reforming health care, but to do both effectively.
This post includes my third thought about selected passages of “So you want to talk about race,” by Ijeoma Oluo. All posts in this series are here.
In several chapters Oluo asks the reader what his or her goals are. In chapter two, “What is racism?” she wrote, “[W]hy are you here?” meaning what do you expect from her book? In chapter three, “What if I talk about race wrong?” she wrote, “Do you know why this matters to you?” meaning why do you want to have a particular race-related discussion?
These are excellent questions, particularly for white people. They can also be turned around and posed as, “Why are you not here?” and “Do you know why this doesn’t matter to you?” (if indeed it doesn’t, or not so much).
That’s more confrontational, perhaps good for getting people’s attention. Do I have yours?
As advised in my first thought post, hold your quick response and actually let these questions sink in. The direction I’d like your mind to go, and the direction my mind is going, is toward exploring what accounts for a white person’s degree of interest in and engagement on race, or lack thereof. As I have best access to my own mind and experience, I will apply this inquiry to myself.
Before I do, I should stop to assess whether this is tantamount to turning the deeply problematic issues around race to being about me (see my second thought, cautioning against just that). I think the answer is, “no.” This isn’t making racial issues about me. This is itself an important racial issue. It matters a lot how much white people engage in addressing racism. It’s a problem we created and perpetuate! Therefore, it is worth pondering what governs the extent we do so.
As evidenced by these posts, my interest in racism has dramatically increased recently. Why was it lower before, and why has it increased? I cannot answer definitively, but I can point to factors I think are relevant and generalizable.
First, there’s the background truth that white people are privileged to be able to avoid consciously focusing on racism. We had and have the power to set things up so we don’t have to. Contrary to claims of reverse racism, we don’t live in a society full of institutions and cultural norms that discriminate against white people. We don’t have 400 years of history of being oppressed.
Instead, the world we inhabit is, by and large, created by us and for us (and if not us, literally, by our white ancestors). We white people are the beneficiaries of that. In contrast to the experiences of people of color, racism is very rarely thrust upon us and certainly not daily.
So, one part of why I could be less focused on racism in the past is because I am white. To the extent I noticed racism, I did not have to deal with it because it did not negatively affect my daily life. It wasn’t a problem I needed to solve just to be comfortable in the world. This is obviously generalizable to other white people. I think it’s inherent in being white in America.
That is not to say I didn’t care about racism or that other white people don’t. I did and others do. But I cared in a way that didn’t matter very much, if at all, to anyone but me. My caring was merely a story about myself I told myself. It didn’t extend very far beyond myself.
Only white people can do that about racism. We get to tell ourselves our own story about what it means to us. People of color do not entirely own the story of racism. They can’t choose to enter or leave it. White people have a choice.
This may explain why I could pay less attention to racism in the past but does not explain exactly why I did so then and what changed to cause me to focus more on it now. Here I have few good answers. However, one big thing that changed was becoming more educated, which is an ongoing process. I’m not done. (In this regard, let me recommend Oluo’s book and also the Seeing White podcast series, the New York Times 1619 Project, and White Fragility, which also is in book length though I have not read the longer version.)
Getting educated is clearly generalizable. Other people can do it. But they need to choose to do it. Why did I choose? Beyond saying that it interested me, I don’t know.
And why did the education have an impact? Part of the answer is that white privilege (and the converse, discrimination of people of color) makes me uncomfortable — not discussing it, but that it exists. The more I understand injustice the less I am able to implicitly choose to accept it by choosing to ignore it, as I once, mostly did. Maybe the generalizable fact here is that many white people will only pay more attention to racism if it becomes too uncomfortable for them not to. Becoming educated is not the only route to discomfort and may not be an effective route for everyone.
I’ll wrap up with a really big question that I won’t answer here. I may, perhaps, try to do so in another post in this series if I figure out how. Oluo ends her book with a call to action. Enough with talk, do something! My question to myself is: about racism, what actions will I take?
The following originally appeared on The Upshot (copyright 2019, The New York Times Company)
The Apple Watch has been quite successful as a smart watch. The company would also like it to succeed as a medical device. The recently published results of the Apple Heart Study in the New England Journal of Medicine show there’s still a long way to go.
An estimated six million people in the United States — nearly 2 percent — have atrial fibrillation, a type of irregular heartbeat that brings increased risk of events like clots, heart attacks and strokes. It’s thought that about 700,000 of people with the condition don’t know they have it
A selling point of the watch is a sensor that can monitor a wearer’s pulse and potentially detect atrial fibrillation.
To test the device’s ability to aid diagnosis, a group of researchers enrolled almost 420,000 Apple Watch wearers in a study. (Some of the researchers were Apple employees, and Apple sponsored the research.) Participants were monitored for about four months. Over that time, 2,161 of the study participants were notified of an irregular pulse, representing just over 0.5 percent of the sample.
Those people were offered telemedicine visits and, if their symptoms were mild, were offered electrocardiogram patches to wear for up to a week to help confirm a diagnosis of atrial fibrillation. Participants mailed the patches back and, if the results indicated an emergency, were contacted immediately and instructed to receive care. If the results were positive for atrial fibrillation but did not require immediate medical attention, the participants were offered a second telemedicine visit and instructed to see their regular physician.
But only 450 of the 2,161 people who were notified about having an irregular pulse returned their sensor patches for evaluation. This means that among those who signed up for the study, wore the watch and got a health alert, almost 80 percent ignored it.
Of the 450 participants who returned patches, atrial fibrillation was confirmed in 34 percent, or 153 people. Those 153 are about 0.04 percent of the 420,000 participants.
This doesn’t mean that the Apple device failed. It probably led some participants to be diagnosed sooner than they might have. How many, and how much of a difference this made in their health, though, is debatable.
Many news outlets reporting on the study mentioned a topline result: a “positive predictive value” of 84 percent. That statistic refers to the chance that someone actually has the condition if he or she gets a positive test result.
But this result wasn’t calculated from any of the numbers above. It specifically refers to the subset of patients who had an irregular pulse notification while wearing their confirmatory patch. That’s a very small minority of participants. Of the 86 who got a notification while wearing a patch, 72 had confirmed evidence of atrial fibrillation. (Dividing 72 by 86 yields 0.84, which is how you get a positive predictive value of 84 percent.)
Positive predictive values, although useful when talking to patients, are not always a good measure of a test’s effectiveness. When you test a device on a group where everyone has a disease, for instance, all positive results are correct.
Other test characteristics like sensitivity (if you have a disease, how likely the test is to be positive) and specificity (if you don’t have a disease, how likely the test is to be negative) are more effective in evaluating the overall quality of a test. This study, unfortunately, was not designed to determine those characteristics.
Other methods to screen and diagnose people with atrial fibrillation are available. A systematic review of mobile health devices for atrial fibrillation found 22 studies between 2014 and 2019 that reported on many of them. Some had sensitivities and specificities pretty close to the ideal of 100. None are close to as large as this study, though.
Even blood pressure monitors, ubiquitous in physician’s offices, can screen for atrial fibrillation. A systematic review of them found that they had sensitivities greater than 85 percent and specificities greater than 90 percent.
Here’s the thing, though. Experts aren’t even sure if screening is a good idea to begin with.
After all, if we felt strongly enough about detecting asymptomatic people who might have atrial fibrillation, we could screen everyone with electrocardiograms. The U.S. Preventive Services Task Force has considered doing this among adults 65 and older, who are at higher risk for stroke. The group found that the evidence was insufficient to recommend doing so, because it’s not clear that this level of screening is better than current care. Just taking a pulse as part of a checkup is a pretty good screen all by itself.
There is also a concern that electrocardiogram screening could turn up a lot of false positives, leading to misdiagnosis and unnecessary further testing, which incurs its own risks. Remember that even with the Apple Watch, most of the people who got notifications did not have atrial fibrillation.
Moreover, the task force was focusing on a population where we might intervene: older people. Patients at high risk of stroke who have atrial fibrillation (i.e., older people) might be treated with anticoagulation. For younger ones at lower risk, it’s not immediately clear how we would treat them, or if we should.
And it’s younger people who are more likely to have a smart watch.
We should be clear that we’re focusing on atrial fibrillation that isn’t otherwise noticed by patients or doctors. Those who are already diagnosed and those who are symptomatic should absolutely be managed by physicians, and many will be treated with medications or procedures. Diagnosed and symptomatic disease should not be minimized or ignored.
There are positive messages from this study. There’s potential to use commercial devices to monitor and assess people outside of the clinical setting, and there’s clearly an appetite for it as well. But for now and based on these results, while there may be reasons to own an Apple Watch, using it as a widespread screen for atrial fibrillation probably isn’t one.
This post includes my second thought about selected passages of “So you want to talk about race,” by Ijeoma Oluo. All posts in this series are here.
Helpfully, Oluo included bulleted lists of things to consider or do (or not to do) in addressing different aspects or consequences of racism. In her list of things to remember when fighting racial oppression as a white person, she wrote:
Build a tolerance for discomfort. You must get used to being uncomfortable and get used to this not being about your feelings […].
There are two ideas here: (1) It’s not about you and (2) get accustomed to psychological/cognitive/emotional discomfort. Both are helpful. Both come up throughout the book.
Acknowledging that point (1) is not to dwell on your own discomfort — because it obviously is not what is important in fighting the oppression of others — I want to think more about the potential sources of discomfort in general (not my discomfort). In particular, I want to think about why engaging in conversations and actions to explore and combat racism is or could be uncomfortable. Really, what I wonder is, does it need to be uncomfortable? Should it be?
In one sense, it 100% should be. That is, an empathetic and moral being should be uncomfortable with unjust treatment of others. This is motivating discomfort. And, obviously, racism is uncomfortable for those on the receiving end of it. I want to make that clear, but remind readers that I’m following Oluo’s lead here and principally talking about the discomfort of white people, so those not on the receiving end.
But I don’t think these are the kinds of discomfort Oluo is getting at, or not the only ones. I think she’s (also) talking about the discomfort one feels when engaging in what we might call a “charged topic,” one associated with lots of arguments, misunderstandings, and resulting hurt feelings and bruised egos. Isms (of which racism is just one) also involve power, dominance, and attendant economic and social privileges, and lack thereof. That’s pretty charged stuff, particularly when people (rightfully) assert they should “get more” and others feel that will mean they will “get less.” (Note: I’m not asserting it is zero sum. I’m suggesting some may worry that it is.)
So, it seems self-evident that racism would be an uncomfortable domain for many. But there is a difference between racism and the challenges and consequences of addressing it and thinking or talking about it/those. Oluo argues for action, not merely words — and I am absolutely not disagreeing with that — but words come first. You (I mean, literally, you) have to talk and think about race and racism before you will act. “Talk” is literally in the title of the book.
And I believe Oluo is also acknowledging that those thoughts and conversations will or could be uncomfortable for you. Is that necessary or valuable? I’m not so sure.
One source of this kind of discomfort could be a cognitive dissonance. You don’t see yourself as racist, yet you must confront your complicity in and influence by structural racism. Oluo wrote,
You have to get over the fear of facing the worst in yourself. You should instead fear unexamined racism. […] Do not fear the opportunity to do better.
She’s acknowledging fear (discomfort) and urging us to get over it. I agree. It’s not really hurting you. You (the white person) are not being harmed here. Dealing with this cognitive dissonance is virtually nothing in the context of 400 years of racism. Get over yourself.
Another source of discomfort could be that you worry that you’ll make mistakes as you engage in the topic of racism. Maybe you’ll accidentally say or write the wrong thing and be called out for it. This is actually a variant of cognitive dissonance. What you think of yourself may not be how you are viewed once you open your mouth. To make matters worse for you, you only have yourself to blame for opening your damned mouth!
I think that source of fear and discomfort (while still minor) needs to be acknowledged to make progress. The vast majority of people do not speak out or write publicly about racism or any particular charged topic precisely because of this fear. It’s why we don’t bring up politics or religion at “polite” gatherings. We’re scared to death of stumbling into an argument and being made a fool.
My view is we should put that out there. We should say, “Yes, this is scary. I might make a mistake.” And then we should say, “But this is too important to let that fear stop me. I will do my best.” Because, let’s be clear, the consequences of that fear turning into a reality for a white person are not very large. If you make a mistake and someone calls you out on it, only your ego will be harmed, if you let it. (Again, virtually nothing relative to racism.) Meanwhile, if you’re doing it right, you will have learned and grown. You’ll be that much better at participating in addressing racism. Isn’t that the point?
I do think (hope) with practice, you can overcome this source of discomfort. I don’t think you need to hold onto it. I am not convinced it is necessary or helpful, even if it is real.
[T]o do better we must be willing to hold our darkness to the light, we must be willing to shatter our own veneer of “goodness.”
I think much of discomfort around white engagement in racism stems from fear of what the light will show. If we’re still uncomfortable, have we really shattered the veneer? If I am nervous about hitting “publish” on this piece, do I still have some work to do. I think so.
Below is the first of several thoughts about some passages of “So you want to talk about race,” by Ijeoma Oluo. This isn’t a review. (Here’s one. Here’s another. Google can help you find more.)
One has to read nearly to the end to encounter one of the most important ideas:
[I]f you are white in a white supremacist society, you are racist. If you are male in a patriarchy, you are sexist. If you are able-bodied, you are ableist. If you are anything above poverty in a capitalist society, you are classist.
Oluo is correct that many would have great difficulty accepting this. And, it does need defending. One need not reflexively agree with it. But let’s put whether it is correct or not aside. I think the first and most important test for you is whether you can suspend judgement of it for a moment and just sit with it. Can you allow for the possibility it is right? Or if it makes you uncomfortable, do you have to reject it immediately?
Actually, I’ll go further than that. I think it’s more important to just let these ideas hang in one’s mind than to be convinced they’re right or wrong. Because to be convinced risks dispensing with them. The easy case is to conclude you’re none of these things and therefore you have no moral responsibility to address them.
The hard case is to conclude you are these things. And even if you take action to address them, you may stop looking for the ways in which you are so.
That is to say, suppose you admit that you must, even if implicitly and subconsciously, harbor some racist ideas and engage in some racist actions (which would be very hard for white people fed a diet of racist media and educational material in the context of deeply racist social structures and institutions to avoid). Accepting this, you might move on without actually exploring the ways in which you are racist (same for sexist, ableist, or classist). Put another way, you might accept you’re racist theoretically but not really “how.” That’s a loss. Shouldn’t you know how?
I think the exploration is where it’s at. No need to conclude anything. Just be open to the possibility and start to notice, look, listen. Better to say, “Aha, here’s a way in which I’m racist” than simply, “I am racist.”
If you really want the defense of the claims in that statement you’ll have to read the book. I’ve given you a brief taste of it in parentheses two paragraphs up, but if that didn’t do it for you, go read the whole thing. More posts on it to come, all under this tag.
Sources like WebMD would have you believing that smoking pot drastically increases your risk of stroke. Let’s see what sources like Healthcare Triage think about that.
Austin and Aaron are participants in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising fees by advertising and linking to amazon.com.
01/16/2020
Austin Frakt
