by Ellen Isaacs
CAN THE U.S. AFFORD TO REMEDY THE RACIAL DIVIDE?
Most articles verifying the effects of racism on health attempt to suggest solutions, ranging from combating provider bias, to changing the insurance system, to reducing income inequality. However, we start by asking a fundamental question: Is it possible to erase the racial differences in health and health care in our capitalist system?
From the point of view of maximizing the economic profits of the system as a whole, only guaranteeing the health and vigor of the employed or destined to be employed or those in the military is a necessity. From a purely economic point of view, the elderly, the chronically unemployed, and the disabled are simply a burden to the system. It is mainly as a result of pressure from the populace that provision is made for them. Medicare, which pays for the care of those over 65 and was born out of the political activism of the 1960s, is very popular, and attempts to cut it back by conservatives have been met with overwhelming opposition. Medicaid, however, which covers care for the poor and disproportionately enrolls non-white patients, has been chronically underfunded. Reimbursements are so low that many doctors and facilities will not accept it, and it is now threatened with massive cuts under Trump. Undocumented immigrants still remain without any coverage whatsoever. Obama care, flawed as it is, is under deep threat.
The difference in wages alone in the U.S., between white men on the one hand and women, minorities, and immigrants on the other, adds up to $3-4 trillion a year, almost 25% of the gross national product. (This can be calculated up from the Bureau of Labor Statistics wage figures.) Some of this is due to different wages paid for the same work and some to the fact that different work is available to women and non-whites with less education and opportunity. In either case, it is not a figure that the economy could afford to erase or even substantially decrease. In addition, one must consider the enormous savings in inferior housing, schools, health facilities and many other services that characterize black, Latino and immigrant neighborhoods. And most important, racism divides groups of workers from one another, with racist and nationalist ideas, and geographic and employment segregation keeping us apart and divided as a fighting force.
Thus we should not expect the racist differentials in health or health care to disappear by virtue of exposing them or because of the good will of politicians. Moreover, as in all the other aspects of racism we discuss in this blog, a two-tiered system lowers the standards and expectations for all. Like all other ills, this one must be attacked by a multiracial movement built from the bottom up.
RACIST INEQUALITY IN HEALTH CARE IS AN INTERNATIONAL PROBLEM
Worldwide, the comparison between the health status of the darker-skinned countries of the southern hemisphere and the wealthier more Caucasian northern countries is shocking. One out of eight people in the world do not have enough food, 98% of whom live in developing countries. The devastating AIDS epidemic continues in Africa, where treatment and preventive services are scarce. Tuberculosis, and drug resistant tuberculosis, are also widespread. The recent smaller outbreaks of the Ebola and Zika viruses reflect inferior public health, prevention and treatment available in Africa and South America. Differences in longevity, nutrition, and multiple infectious diseases persist in the less developed world due to lasting effects of colonization, continued exploitation of labor and resources, and proxy imperialist wars.
It is not uncommon for Americans of good will, in highlighting the injustice and inequality in colonized or militarized societies, to point out the striking differences in health and longevity between the rich and poor, the rulers and the ruled, the white and the non-white populations. In Israel/Palestine, there is a ten year gap in life expectancy between Jews and Palestinians, and a five fold difference in infant mortality. In South Africa, based on data from 2012, black men had an 18 year shorter life expectancy than white men, 17 years after the end of apartheid. We use such statistics to bolster our diatribes against the horrors of occupation or apartheid, but sometimes we forget that racial disparities of a large degree persist and exist in our own supposedly democratic society, free of internal armed conflict, walls, enforced segregation or occupation.
RACISM AND HEALTH IN THE U.S.
A century ago, W.E.B. Dubois said “The Negro death rate and sickness are largely matters of [social and economic] condition and not due to racial traits and tendencies” This year, the renowned Harvard sociologist David R. Williams talked about how every seven minutes, a black American dies prematurely, over 200 people each day who would not die if their health were the same as their white counterparts. (https://www.ted.com/talks/david_r_williams_how_racism_makes_us_sick ) He presented evidence that these racial differences cannot simply be accounted for by unequal economics and education, because even within groups of equal income and education, racial gaps persist. Only racism can be the answer. Even among college graduates, there is a 4.2 year black/white gap in life expectancy, and it rises for each lower rung of achievement.
Racism, he said, can be measured both in the gross insults like excess stops by the police, and in the small effects of everyday slights. These may include less courteous treatment in a restaurant, poorer service at a store, or expressions of fear by fellow pedestrians, High blood pressure, obesity, cancer, heart disease and premature death have all been shown to correlate with the experience of everyday racism. Another factor is different access to medical care, which reflects housing and employment discrimination. In addition to these institutional factors, implicit bias, or unconscious racism, occurs among many health care providers, even well-intentioned ones.
The Lancet, a major British medical journal, has just published a new issue devoted to the inequities in American health and health care, and “In the nearly 3 years since the first Series was published, health in the USA has changed and not for the better” (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)30939-X/fulltext). The article on structural racism, that not dependent on the actions of individuals, focuses on the experience of black Americans and reiterates the history of the creation of racism to justify slavery and the later use of eugenics and genetic “science” to perpetuate white supremacy. Despite the passage of civil rights legislation in the 1960s, structural racism persists in residential, occupational, educational, and judicial differences determined by discrimination in rental policies, job training and wages, school variations and discrepancies in arrests and sentencing.
According to the 2010 census, the average white American lives in a neighborhood that is 75% white, and the neighborhood of a typical black American is 65% non-white, figures unchanged since 1940. Poorer neighborhoods with high black populations are characterized by lower quality housing, more pollutants and toxins, less availability of healthy food and less access to quality health care. These conditions lead to higher neonatal morbidity, a lower life expectancy and an increased risk of chronic disease, such as cancer and diabetes.
†Wealth, poverty, and potential life lost before the age of 75 years are reported for the black population only; all other data are for the black non-Hispanic population.‡Serious psychological distress in the past 30 days among adults aged 18 years and older is measured using the Kessler 6 scale (range=0–24; serious psychological distress: ≥13). Sources: wealth data taken from the US Census; 1 x 1 US Census Bureau. Detailed tables on wealth and ownership assets: 2011. http://www.census.gov/people/wealth/data/dtables.html. ( (accessed Jan 25, 2017).)
As pointed out in the review article published by the National Institutes of Health (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4306458/), segregation in the workplace often creates different levels of risk. For example, at a federal nuclear power plant, black workers had a greater level of radiation exposure. Minority workers often work in more dangerous environments, such as buildings without fire exits or less secure scaffolding. They also often encounter conditions that lead to increased stress, such as lack of breaks or late or underpayment of wages. Such stress, exclusive of physical hazards, is related to an increased incidence of heart disease.
Hospitals and nursing homes also remain highly segregated. Sometimes patients are separated by types of insurance, which correlates with race and income, into separate areas within the same facility. In New York City, public hospitals, for patients with Medicaid or no insurance, are often paired with voluntary hospitals next door. For example, Bellevue sits next to New York University Hospital in Manhattan, and North Central Bronx is adjacent to Montefiore Medical Center in the Bronx. The city hospitals have fewer services and amenities and doctors in training have more responsibilities and less supervision.
Overall, the U.S. ranks last or near last in nearly all measures of health outcomes, health equity, and systems of delivery (https://www.forbes.com/sites/danmunro/2014/06/16/u-s-healthcare-ranked-dead-last-compared-to-10-other-countries/#76bd1600576f). Even health outcomes for the well insured with access to the “best” care lose in comparison to similar groups in European countries, despite the U.S. being the highest spender. This reflects the emphasis on expensive high-technology procedures, unregulated drug pricing, and high insurance company profits. It also reflects the lack of emphasis on prevention, including healthy food, a safe environment and working conditions, minimizing stress, and exercise facilities.
A sharply divided society by class and race hinders everyone from attaining a healthy and long life. Even the better off suffer from a health care system built to insure profits rather than outcome. The lowered expectations that result from the presence of millions of residents with little or inferior health care and health bring down the standards for all. Racism, in large part, allows this double standard to be tolerated and weakens the impetus and ability to wage the battle needed to gain a medical care system that we all deserve.
The tables in the appendix to this article summarize some of the sharp racial differences in health and health outcomes in New York City, results not unlike those in most American cities.
New York City Health Indicators by Race/Ethnicity, 2012-2014
|Percentage of population (2014)||33.1%||23.1%||14.5%||29.0%||100.0%|
|Median annual household income in US dollars~||75,596||41,729||56,440||36,436||52,737|
|Percentage of families below poverty~||8.2%||19.9%||18.0%||26.7%||17.5%|
|General Health Indicators|
|Total mortality per 100,000 population, age-adjusted||579.0||696.7||360.7||509.1||580.7|
|Percentage of premature deaths (< 75 years)||32.3%||56.4%||46.5%||53.7%||44.1%|
|Years of potential life lost per 100,000 population, age-adjusted||4,551||7,797||2,735||4,228||5,112|
|Number of births per year (3 year average)||36,446||23,981||19,553||35,772||117,301|
|Percentage of births with early (1st trimester) prenatal care||80.8%||62.3%||73.9%||67.1%||71.6%|
|Percentage of births with adequate prenatal care (Kotelchuck index)||75.8%||58.1%||70.4%||64.6%||67.7%|
|Percentage of premature births (< 37 weeks gestation)||8.3%||14.6%||9.2%||11.6%||10.8%|
|Percentage of low birthweight births (< 2.5 kg)||6.2%||12.0%||7.9%||7.8%||8.2%|
|Teen pregnancies per 1,000 females aged 15-17 years||7.1||43.1||1.7||38.1||29.8|
|Pregnancies per 1,000 females aged 15-44 years||77.6||123.2||65.7||104.9||101.3|
|Fertility per 1,000 females aged 15-44 years||59.3||54.1||65.4||63.2||60.8|
|Infant mortality per 1,000 live births||2.6||7.3||2.2||3.6||4.2|
|Respiratory Disease Indicators|
|Asthma hospitalizations per 10,000 population, age-adjusted||7.8||44.1||5.6||33.8||27.6|
|Asthma hospitalizations per 10,000 population, aged 0-17 years||8.9||74.6||9.2||44.3||44.4|
|Chronic lower respiratory disease mortality per 100,000 population, age-adjusted||22.4||21.3||12.1||17.7||20.4|
|Chronic lower respiratory disease hospitalizations per 10,000 population, age-adjusted||19.6||57.1||9.8||44.2||40.0|
|Heart Disease and Stroke Indicators|
|Diseases of the heart mortality per 100,000 population, age-adjusted||194.8||215.5||98.1||143.8||184.2|
|Diseases of the heart hospitalizations per 10,000 population, age-adjusted||70.4||106.8||36.1||73.6||94.0|
|Cerebrovascular disease (stroke) mortality per 100,000 population, age-adjusted||16.4||24.2||18.8||20.1||19.7|
|Cerebrovascular disease (stroke) hospitalizations per 10,000 population, age-adjusted||15.4||29.1||11.6||17.5||22.8|
|Coronary heart disease mortality per 100,000 population, age-adjusted||174.4||191.1||87.9||128.3||164.2|
|Coronary heart disease hospitalizations per 10,000 population, age-adjusted||25.6||29.7||17.1||26.9||34.2|
|Congestive heart failure mortality per 100,000 population, age-adjusted||5.8||5.7||2.3||4.1||5.3|
|Congestive heart failure hospitalizations per 10,000 population, age-adjusted||16.4||39.2||7.6||22.5||26.3|
|Diabetes mortality per 100,000 population, age-adjusted||12.8||36.6||13.2||21.8||20.4|
|Diabetes (primary diagnosis) hospitalizations per 10,000 population, age-adjusted||10.0||37.3||5.0||22.6||22.4|
|Diabetes (any diagnosis) hospitalizations per 10,000 population , age-adjusted||138.1||336.3||100.7||250.6||250.0|
|Diabetes short-term complications hospitalizations per 10,000 population aged 6-17 years||1.1||5.0||0.5||3.0||3.3|
|Diabetes short-term complications hospitalizations per 10,000 population aged 18+ years||2.5||13.5||0.9||6.9||7.1|
|Lung cancer incidence per 100,000 population, age-adjusted (2011-2013)||59.0||49.7||45.0||33.0||49.7|
|Colorectal cancer mortality per 100,000 population, age-adjusted (2011-2013)||14.2||18.3||10.7||13.6||14.7|
|Colorectal cancer incidence per 100,000 population, age-adjusted (2011-2013)||42.0||44.7||34.2||34.2||40.5|
|Female breast cancer mortality per 100,000 female population, age-adjusted (2011-2013)||21.7||27.8||8.9||15.5||20.7|
|Female late stage breast cancer incidence per 100,000 female population, age-adjusted (2011-2013)||46.7||50.3||30.0||34.4||42.5|
|Cervix uteri cancer mortality per 100,000 female population, age-adjusted (2011-2013)||1.9||4.8||1.9||3.3||2.9|
|Cervical cancer incidence per 100,000 female population, age-adjusted (2011-2013)||7.1||11.6||9.5||9.6||9.3|
|Substance Abuse and Mental Health-Related Indicators|
|Drug-related hospitalizations per 10,000 population, age-adjusted||20.8||33.8||1.9||22.6||26.1|
|Suicide mortality per 100,000 population, age-adjusted||8.1||3.5||5.4||4.4||5.8|
|*||Fewer than 10 events in the numerator, therefore the rate or percentage is unstable|
|s||Data are suppressed. The data do not meet the criteria for confidentiality|
|~||White non-Hispanic, Black (including Hispanic), Asian (including Hispanic, excluding Pacific Islanders), and Hispanic|
Data do not meet the criteria for statistical reliability or data quality, or data not available