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The author of several studies on the issue and editor of the book Race, Ethnicity and Health, Thomas LaVeist is driven to find answers to the question that lies at the center of his work and his passions—a question that happens to be the title of his current book-in-progress: Why [do] African Americans Live Sicker and Die Younger?
LaVeist first encountered the question of survival rates among ethnic and economic groups in a used bookshop near the University of Michigan campus, where he was pursuing a doctorate in political sociology. Thumbing through a book about the sinking of the Titanic, he came across a list that categorized the percentage of female survivors based on the type of passage they had booked. “Virtually everyone with a first-class ticket survived, and it went down from there,” he says. “I thought, Wow, even on a sinking ship, your economic status determines whether you live or die.” Later, working on a study of black political power in cities, he was trying to determine quality of life in various districts. “Over and over, health indicators came up as the way to measure quality of life,” he says. Realizing that health issues were drawing his interest, LaVeist soon switched his specialty to medical sociology and followed up with a postdoc at the University of Michigan School of Public Health, and eventually made his way to Johns Hopkins in 1990.
He has been envisioning a center for the study of health disparities ever since he arrived. Now, thanks to a $6 million grant from the National Institutes of Health (NIH), Hopkins will join forces with Baltimore’s Morgan State University to create the Morgan-Hopkins Center for Health Disparities Solutions . With the new Center’s other director, Morgan professor of public health Dorothy Browne, LaVeist will embark upon a mission of educating researchers, working with community organizations to address disparities, and conducting primary research. Perhaps most important, the new Center will try to see that the issue of health disparities is recognized and understood by the public, the health care industry, and policy makers.
As one of its first undertakings, the new Center is casting its eye on the Union Square and Montclair neighborhood that surrounds the Miracle Temple. Students will interview and screen each of the 3,555 adults in the area, LaVeist says, to determine such basics as blood pressure, weight, and medical conditions. And the students will probe the residents’ lifestyles, their home environments, and the substances they take into their bodies.
Over time, the project is meant to determine how these details correlate with health outcomes, LaVeist says, and to answer the question, “Is there a racial disparity in health after adjusting for the characteristics of the community?” After all, says LaVeist, “The people here are exposed to the same environmental hazards and living conditions.” And while there doesn’t seem to be much racial strife, he wryly points out that the neighborhood isn’t lacking for tension: The residents, here, he says, “live together, hang out together, sell drugs together, break into cars together.”
The inequities between health care delivery to blacks and whites captured the public’s attention in 1999, with a study published in the New England Journal of Medicine. The study enlisted actors, both African-American and Caucasian, to portray patients with various heart-related health complaints. Their visits to doctors were then videotaped. The tapes revealed that even when these “patients” presented with identical symptoms, the doctors’ referrals varied widely according to race, with African-American women receiving the fewest referrals for cardiac catheterization—a crucial next step to diagnosing heart disease.
The study, by Kevin Schulman, then at Georgetown (and now director of the Center for Clinical and Genetic Economics at Duke University), was featured on TV’s Nightline, where it sparked a public uproar and caught the attention of Congress. The Department of Health and Human Services commissioned a study by the Institute of Medicine (IOM), an independent organization frequently called upon to advise the federal government. The IOM’s mandate? To determine whether there are differences in care among racial groups.
A panel of 15 experts (including Martha Hill, dean of the Johns Hopkins School of Nursing, and Donald Steinwachs, chair of the Department of Health Policy and Management at the School of Public Health) convened to sort through the available research for some answers. The resulting report, “Unequal Treatment,” was released in March 2002.
This was not an empirical study, according to Brian Smedley, who as senior program officer for the IOM directed it. Rather, it was an analysis of more than 100 published papers, including some by LaVeist, to examine whether there are differences in the care that minority groups receive compared to whites, and further, to determine whether disparities continue to occur even after variables such as insurance and income status have been controlled for.
After its 18-month review, the committee could only conclude that the reasons for health care disparities are myriad and complex. Cultural and language barriers, time limitations imposed by managed care, and a general distrust for the health care establishment on the part of minority patients can all contribute to unequal treatment. But one of the panel’s most significant conclusions is one that many doctors would vehemently deny: that those in the medical profession bring bias, racism, and stereotypes to the patient/provider relationship. Says Smedley, “We may harbor stereotypes that we are not consciously aware of.”
Notes LaVeist, “There are many assumptions about the differences between blacks and whites.” He points to a 2000 study in Annals of Emergency Medicine, in which blacks and Hispanics visiting the emergency room were less likely than whites to be prescribed pain killers for broken limbs. The unspoken inference, perhaps dating back centuries to the time of slavery, was that blacks have a higher tolerance for pain than whites. “This is an egregious example of unequal treatment,” he says. “Much of what happens is much more subtle.”
For better or for worse, time-pressed practitioners may unwittingly rely on racial stereotyping, says Donald Steinwachs, PhD. “One of our human strengths is generalizing. When we meet someone, we often make assumptions about their education and background based on their resemblance to other people we have known,” he says. But it’s also one of our weaknesses. In doing so, we may not listen as carefully.” And this, he believes, may be a failing in clinical encounters.
|LaVeist and colleagues from A Faith Center for Community Wellness and Advancement discuss issues affecting the health of a South Baltimore neighborhood.|
LaVeist tells of his sister’s experience when she learned she was pregnant. “The doctor immediately began counseling her on options for abortion and adoption. She said, ‘I guess I would have to discuss this with my husband and two children.’” LaVeist laughs and says: “I don’t think the doctor was consciously saying to himself, ‘This is a black woman, she must be poor and unmarried.” Nevertheless, something like this assumption apparently affected his approach to his patient.
LaVeist himself had a similar encounter: Working out at his gym one day, he hit his head badly. “There was a lot of blood, so they took me to the emergency room,” he recalls. There, an intake nurse took one look at him and said, “You don’t have health insurance, do you?” LaVeist informed her that, yes, he was insured. Once he revealed his occupation and his employer, he says, “everything changed. Instead of giving me a Band-Aid and sending me home, I was suddenly getting the best quality health care anywhere.” Not all black males, insured or not, he suspects, are so fortunate. “A lot of times patients don’t even know they have been victims.”