New Reasons for Outrage Over Persistence of Healthcare Disparities: Ignorance and Neglect
Although various studies indicate that lower socio-economic status is the most powerful determinant of health, there have been a plethora of studies over the past two decades showing that there are disparities in access and outcomes of care between whites and communities of color, especially black and brown. Tellingly, these disparities even occur in the Medicare system, where there is a presumption of equal access. Race and socio-economic status are regrettably important factors in determining life expectancy. There has been a persistent gap in mortality between whites and blacks for many decades, with one study showing that blacks suffer approximately 800,000 “excessive deaths” over a 10-year period relative to whites. More recently, studies have demonstrated that the wealthiest Americans live more than 8 years longer than less wealthy Americans and, tragically, color is still a marker for poverty in our country.
In 2002, The Institute of Medicine issued a report, “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care.” The report described basic factors that support the persistence of racially-based healthcare disparities: differences in patient preferences, unfair and inequitable operations of the healthcare system, and frank racism and discrimination.
Black and White Pain
Now, a recent spate of articles adds THREE more factors responsible for persistence of healthcare disparities: ignorance, neglect, and lack of conviction to change the status quo. Earlier this month the National Academy of Sciences published the results of a University of Virginia study in which 222 white medical students and residents were asked to rate on a scale of zero to 10 pain levels they would associate with two mock pain cases – for both a white and black patient. It was not surprising that the students rated pain lower for black patients than whites and chose less aggressive treatment options for people of color, because disparities in pain assessment and treatment have been reported for decades. The students were simply reflecting this unfortunate reality.
More disturbing were the reasons underlying the students’ choices. For example, 8% and 14% of first- and second-year medical students, respectively, endorsed the belief that “blacks’ nerve endings are less sensitive than whites’” and 29% of first-year and 17% of second-year medical students endorsed the belief that “black people’s blood coagulates more quickly than whites’.” On average, about 50% of participants reported that at least one of the false belief items as probably or definitely true.
These and other responses reflect frankly racist myths and misconceptions and conform to stereotypes that many of us had hoped were long ago vanquished. Of great importance, the study also found that “racial bias in pain perception is associated with racial bias in pain treatment recommendations.”
Explaining the Bias
There are likely many reasons other than poor medical school pedagogy for this ignorance. According to 2013-2016 American Association of Medical College Statistics, only 7.8% of applicants to U.S. medical schools are African-Americans (compared to 48% whites and 19.3% Asian). Although we do not have data on the racial demographics of the University of Virginia medical school class, one can only wonder if racial and socio-economic factors among the respondents in the study were such that they had little exposure to blacks. This would not be surprising. Many commentators have reported that one of the reasons for persistence of the racial divide in the U.S. is that we are, as the award-winning author David Shipler described in the title of his book, A Country of Strangers. The relatively affluent and privileged applicants that apply to medical school and eventually become doctors likely grow up with little exposure to African-Americans.This level of biological ignorance among medical personnel is, as the authors of the study said, “highly surprising.” We would add that it is unacceptable and outrageous. But how does one explain this level of ignorance in otherwise highly intelligent and educated medical students? One can only assume that these data would be similar in other medical schools, although this needs further study. One can speculate that some of this ignorance is related to implicit racially-based biases (which by definition operate at a subconscious level) that all persons exhibit, even doctors.
It is important to see how we in the bioethics community respond to the University of Virginia and similar studies. Recently, a spate of articles criticizing the relative lack of commentary and activity related to the negative effects of racism in medicine have appeared in the bioethics literature. The April issue of the American Journal of Bioethics focused on this problem. Pointing to a paucity of articles and analysis of the impact of racism on the persistence of health disparities, and the failure of bioethicists to address this issues over time, John Hoberman claims in a recent Hastings Report article that the field of bioethics has a “race problem” and that the “ moral imagination in bioethics has largely failed African-Americans.” The neglect of targeting the obvious injustice of persistence of racially-based health disparities by the sharp analytical and philosophical minds in bioethics is an outrage and must be remedied.
All of us who analyze or deliver healthcare or who create policy to regulate and administer it are obligated to respond to injustice. Not to do so is an outrage. Thomas Jefferson once said: “Do you want to know who you are? Don’t ask. Act! Action will delineate and define you.” These are wise words indeed. Put another way, the persistence of inaction will condemn us as moral failures.
Richard Payne, MD, holds the John B. Francis Chair at the Center for Practical Bioethics and the Esther Colliflower Professor of Medicine and Divinity at Duke Divinity School, Duke University.
Myra Christopher holds the Kathleen B. Foley Chair in Pain and Palliative Care at the Center for Practical Bioethics.