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Paper Contributions
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416 UNEQUAL TREATMENT: CONFRONTING RACIALAND ETHNIC DISPARITIESIN HEALTH CARE
cult to separate healthcare administration choices that harm poor people from those that harm
members of racial and ethnic minority groups. This is particularly true in the case of programs
such as Medicaid, where coverage is specifically aimed at the poor and medically indigent.
Second, even if U.S. lawmakers were to enact a totally reformed system that utilizes a
single payer with common coverage and payment rules, research from other nations suggests that
minority and poor residents nonetheless would continue to experience reduced healthcare access
and poorer health outcomes. The literature on disparities in healthcare access is replete with ex-
amples of disparate access to care and disparate utilization of health services. (Mayberry, 2000,
Lillie-Blanton et. al. 20001. The most recent example can be found in a 2001 Surgeon General's
report examining racial and ethnic disparities in the use of mental health services by members of
racial and ethnic minority groups, which speculates on the underlying causes of disparity in ac-
cess, utilization and quality and concludes that the principal factors are cost, poor services in
poor communities, cultural and communications barriers, fear of the health system, and general
overall problems in the relationship between patients and providers (Surgeon General, 20011.
This focus on provider/patient communication difficulties, fear of the system, and cultural isola-
tion in healthcare appear to be recurrent themes throughout the literature on healthcare dispari-
ties.
Furthermore, the evidence on disparate access to care even where insurance is technically
not a barrier is hardly unique to the United States. For example, studies of the apparently com-
mon practice of using government-sponsored community health clinics in nations with national
health systems typically point to the need for such service delivery interventions because of ac-
cess barriers related to race, ethnicity, culture and poverty (Hawkins et. al., 2000 Consequently,
even aggressive efforts to reduce discaritv-causin~ choices in the administration of healthcare
.L , ~ ,
. .. `. . .. . . . .. . . . .. . ...
financing programs could nonetheless continue to leave minority and low- income patients with
unequal access.
Third, even substantial incremental reforms that improve existing programs but leave
them in tact inevitably would leave millions of Americans dependent on sources of healthcare
financing that are perceived as other than "mainstream," and thus subject to the misapprehen-
sions that enrollment in "lesser" programs brings with it. The data reviewed for this study sug-
gest that incremental reforms would leave a racially and income-identifiable group of Ameri-
cans disproportionately enrolled in forms of healthcare financing that are less attractive to
healthcare providers because they cover less, pay less, and carry unpleasant connotations and
associations, such as bureaucratic hassles and the status of a "poor people's program." This
lesser form of coverage in effect validates on business grounds what may be underlying prejudi-
cial leanings on the part of members of the medical care industry.
Finally, and as noted at the outset, any assessment of the limitations of directly financed
public insurance programs such as Medicare and Medicaid must be read against a backdrop of
their extraordinary accomplishments over the past three and a half decades. Since their incep-
tion, Medicare and Medicaid have literally remade the American healthcare system for minority
Americans, opening access that previously had been denied. At the time of their enactment,
white Americans were hospitalized 27% more frequently than African Americans and members
of other minority groups, and in the case of elderly persons, the racial gap stood at 70%. By
1975, the gap had narrowed to 4% overall and 14% among the elderly (Davis and Schoen,
' At one time, dependence on Medicaid was viewed by health providers and policy makers as stigmatizing. As Medicare has become in-
creasingly complicated and overall payment has declined in relation to the overall cost of care, anecdotal evidence suggests that reliance on
Medicare (either alone or in combination with Medicaid) may be producing similar reactions within the health system.
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Racial and Ethnic Disparities
in Diagnosis and Treatment:
A Review of the Evidence and a
Consideration of Causes
H. lack Geiger, M.D.
City University of New York Medical School
INTRODUCTION
At no time in the history of the United States has the health status of
minority populations African Americans, Native Americans and, more
recently, Hispanics, and several Asian subgroups equaled or even ap-
proximated that of white Americans. The health of all American racial
and ethnic groups has improved dramatically, particularly over the last
six decades, but the paired burdens of excess morbidity and decreased life
expectancy for people of color have been noted over several centuries and
have proved, even recently, to be stubbornly resistant to substantial
change (Byrd and Clayton, 2000; National Center for Health Statistics,
1998~. Two observations, some four decades apart, illustrate this persis-
tence of inequality. In his classic 1944 study of the role of race in American
life, Gunnar Myrdal noted that "Area for area, class for class, Negroes
cannot get the same advantages in the way of prevention and care of dis-
ease that whites can" (Myrdal, 1944~. In 1985, the Report of the Secretary's
Task Force on Black and Minority Health concluded that "Despite the
unprecedented explosion of scientific knowledge and the phenomenal
capacity of medicine to diagnose, treat and cure disease, Blacks, Hispan-
ics, Native Americans, and those of Asian/Pacific Islander heritage have
not benefited fully or equitably from the fruits of science or from systems
responsible for translating and using health sciences technology"
(USDHHS, 1985~. In 1995, the overall African-American mortality rate
was 60 percent higher than that of whites precisely what it had been in
1950 (Williams and Rucker, 2000; Williams, 1999~.
417
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UNEQUAL TREATMENT
Classic public health doctrine holds that the major determinants of
population health status and the primary explanations of disparities
among population groups lie in the social, physical, and economic envi-
ronments, which in turn are determined by the larger society's norms,
values, social stratification systems and political economy (King, 1996;
Menefee, 1996~. The causes of these minority/white disparities in health
status have consistently been attributed to such variables as socioeco-
nomic status (especially income, lack of education, and unemployment);
lifestyle choices and behavioral risks; occupational and environmental
hazards, inferior housing, poor nutrition, and different cultural beliefs
about health and illness. There is evidence for all of these variables. An-
other explanation is lack of minority access to health care, particularly the
lack of either public or private health insurance, which has persisted de-
spite the introduction and expansion of such programs as Medicare and
Medicaid (Blendon et al., 1989; Weinick, Zuvekas, and Cohen, 2000~.
Two other variables frequently suggested as causative similarly re-
flect values and beliefs that are prevalent in the larger society and appear
with considerable frequency in the medical literature on disparities. The
first of these is the contention that there are biologically and genetically
distinct human races, and that "racial" biologic differences in susceptibil-
ity to, manifestations of, or therapeutic responses to specific diseases are
significant pathophysiologic contributors to health disparities. Such be-
liefs appeared frequently in l9th-century America as elaborate, pseudo-
scientific arguments for the inherent biological inferiority of African
Americans (Cartwright, 1851~. ~
today, however, despite the recognition
that "race" is a social rather than a meaningful biologic concept (Marks,
1995; Cavalli-Sforza, Menozzi, and Piazzi, 1994; Witzig, 1996), arguments
about the medical importance of racial groupings continue to appear,
without pejorative intent and in highly sophisticated form (Wood, 2001;
Schwartz, 2001; Goodman, 2000~.
The second suggestion is that racial and ethnic discrimination itself
may be an important contributor to health disparities, not merely through
the historic and persistent disadvantages it creates for minorities in the
American social structure, but also specifically through health provider
bias conscious or unconscious, individual or institutional. A rich litera-
ture attests to the persistence and prevalence of racist beliefs and discri-
minatory behaviors in contemporary American society (Steinhorn and
Diggs-Brown, 1999; Walter, 1998; Polednak, 1997; Massey and Denton,
1993; Hacker, 1992; Feagin, 1991; Farley and Allen, 1989~. There was lim-
ited quantitative evidence, however, for the view that such racial/ethnic
discrimination might occur frequently in medicine until the availability of
large administrative databases from Medicare, the Health Care Financing
Administration (HCFA), the Department of Veterans Affairs (VA) and
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RACIAL AND ETHNIC DISPARITIES IN DIAGNOSIS AND TREATMENT 419
other sources initiated a growing stream of studies examining racial and
ethnic disparities in diagnosis and treatment. These studies clearly estab-
lished that whatever the causes, the experience of minorities within the
health care system differed from that of comparable whites across a broad
range of disease categories. The majority of these investigations focused
on African-American patients; data on Hispanics, Native Americans, and
Asian/Pacific Islanders were more limited.
In 1990, the American Medical Association (AMA) took formal note
of black-white disparities in health care. While emphasizing the probable
roles of socioeconomic status and sociocultural factors and noting the limi-
tations of many studies, the AMA also acknowledged that "Disparities in
treatment decisions may reflect the existence of subconscious bias....
The health care system, like all other elements of society, has not fully
eradicated this [racial] prejudice" (Council on Ethical and Judicial Affairs,
1990~. Intense discussions of the early evidence and its possible causes,
however, were already underway. A search of the literature prepared for
the AMA's board of trustees covering only the articles, commentaries and
letters that appeared in the Journal of the American Medical Association
and the New England Journal of Medicine from 1984 to 1994, filled 66
single-spaced pages (Board of Trustees Report 50-1, 1995~. The comments
of many physicians were heavily weighted toward denial. As van Ryn
has pointed out, such reluctance is understandable because the idea that
racial/ethnic bias might be operative conflicts with most physicians' con-
scious commitment to anti-discriminatory principles, their views of their
own behaviors, that of their peers and the institutions within which they
work, and the ethical commitments of medicine (van Ryn, 2001~.
Studies of racial/ethnic disparities in diagnosis and treatment prolif-
erated throughout the l990s and were characterized by increasingly so-
phisticated control or adjustment for such confounding variables as health
insurance status, income and education, severity or stage of disease, co-
morbidity, and hospital type and resources. They drew upon a wide vari-
ety of datasources, regional and multi-center collaborations, quality as-
surance investigations, and disease-specific investigations such as the
Coronary Artery Surgery Study (CASS). Relatively few were based on
detailed access to clinical records. The limitations of administrative data-
bases and retrospective methodologies usually precluded any evidence-
based identification of the causes of disparities. Explanations, which were
necessarily speculative in most cases, were drawn from the same repeti-
tive list of possibilities. They included patient choice or preference, un-
measured aspects of socioeconomic status, unmeasured clinical variables,
biological differences in disease manifestation or response to treatment,
minority cultural beliefs, lack of trust in the health care system, deficien-
cies in providers' cultural competence, and difficulties in cross-racial/
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UNEQUAL TREATMENT
ethnic physician-patient communication, in addition to the possibility of
individual or institutional bias. In the late 1990s, concerns about racial/
ethnic bias and stereotyping appeared with increasing frequency in the
medical literature (Geiger, 1996, 1997; King, 1996; Smith, 1998; Williams
and Rucker, 2000) and began to be presented as issues of social justice
(McGary, 1999~. Recently, local governments and public health depart-
ments have conducted studies of racial/ethnic disparities and discrimina-
tion in health care institutions in their own areas (Twin Cities Metro Mi-
nority Health Assessment, 2001; Seattle and King County Public Health
Department, 2001~. At the federal level, Congressional legislation has spe-
cifically addressed issues of discrimination in health care, and a new Na-
tional Center on Minority Health and Health Disparities has been estab-
lished at the National Institutes of Health. Clearly, the problem of racial/
ethnic disparities in diagnosis and treatment is increasingly being viewed
as an important subset of the issue of achieving equity in health status
(Department of Health and Human Services, 2000) and as a particularly
troubling component of the problems of race and ethnicity in the larger
society.
It is in this context that systematic reviews of the relevant medical
literature may help to illuminate three key questions. Does the cumula-
tive weight of evidence establish that there are significant racial and ethnic
differences in diagnostic investigation and therapeutic recommendations
and actions, due at least in part to problems of bias and discrimination? If
so, do such differences in health care in turn contribute to the excess bur-
dens of morbidity, disability, impaired quality of life and premature mor-
tality that are already so well documented in studies of the health status
of minority populations? Finally, what can be determined about the mul-
tiple processes and causes of these differences? The answers may be help-
ful in addressing two additional questions: What are the needs for further
research, and what steps might be taken now to reduce or eliminate such
disparities?
The Present Review: Scope and Methods
This paper will present a sampling of findings from an ongoing re-
view of the medical literature on racial and ethnic differences in diagnosis
and treatment. Relevant studies were identified by searching Medline
and many other databases, including those maintained by HCFA, the
Agency for Healthcare Research and Quality (AHRQj, and the HHS Of-
fice of Minority Health (OMH). Additional studies were identified
through references in published articles. A substantial number of dedi-
cated web sites relevant to issues of minority health, cultural competence
and health workforce diversity were examined, as were a wide variety of
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RACIAL AND ETHNIC DISPARITIES IN DIAGNOSIS AND TREATMENT 421
reports from the Henry I. Kaiser Family Foundation, the Commonwealth
Fund, the Association of American Medical Colleges (AAMC), the Na-
tional Medical Association (NMA), the Hispanic Medical Association
(HMA), and other organizations. Editorials, commentaries, and work-
shop and conference reports were also reviewed. In all, more than 600
bibliographic citations have been accumulated and organized primarily
by disease category. Topics include general medical care, coronary artery
and other cardiac disease, cancer, cerebrovascular disease, asthma, HIV/
AIDS, renal disease and renal transplantation, diabetes, mental health,
maternal and child health, ophthalmic disease, prevention, and a small
sampling of other disease categories. An effort was made to identify all
relevant studies comparing diagnosis and treatment by race or ethnicity,
including any that did not report significant disparities. Additional topics
include research methods and clinical trials, issues of trust and communi-
cation in the healthcare system, and medical education and cultural
competence.
A hard copy of each article was obtained from the library and exam-
ined for relevance, study design, appropriateness of data sources, ana-
lytic methods and control of potentially confounding variables, and origi-
nality. Each selected article was then reviewed by at least two people a
physician with epidemiologic training and a master's or doctoral level
epidemiologist or health services researcher. A detailed one- or two-page
annotation was then prepared, including not only the material usually
presented in the abstracts purpose, data sources, study design, methods
and results but also important details from the text such as the discus-
sions, the offered explanations, the acknowledged limitations, and any
statements of implications for policy or research. Initial support for this
work was provided by the Robert Wood Johnson Foundation, and sup-
port for what is now an ongoing effort has been provided by the Josiah
Macy, Jr., Foundation, the Commonwealth Fund, the Ford Foundation,
and the W.K. Kellogg Foundation.
This effort substantiates and extends the pioneering work of Mayberry
and his associates, who published the first detailed and comprehensive
review of the relevant medical literature (Mayberry, Mill, and Ofili, 2000~.
As indicated by the list of topics, the scope of the present effort was some-
what broader, as was the time frame. A few studies and commentaries,
mostly in the psychiatric literature, were found in the 1960s (Gross and
Herbert, 1969; Pasamanick 1963) and a small number of relevant publica-
tions appeared in the 1970s. The majority of articles selected for this re-
view, however, were published between 1980 and the first half of 2001.
Our purpose in the following sections is not to present an exhaustive
account or description of each annotation in every topic category, a task
that would require a much longer paper. Instead, a modest number of
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UNEQUAL TREATMENT
studies, selected as representative of the most important findings, will be
described and discussed in the following section on general medical and
surgical care. This will give some sense of the data sources, study designs
and methods that are typical of the entire research effort. In subsequent
sections, an attempt will be made to present representative studies in each
of five disease categories. These examples from the literature review are
intended to document the multiplicity of factors, including but by no
means limited to individual and institutional bias, that contribute to racial
and ethnic disparities in diagnosis and treatment.
General Medical and Surgical Care
Perhaps the most useful data come from large-scale studies that ex-
amine racial/ethnic differences in the adequacy, intensity and quality of
diagnostic and therapeutic procedures for a wide range of clinical condi-
tions, in different hospital types and health care systems For example,
Kahn and her colleagues examined the quality of care provided to a na-
tionally representative sample of 9,932 elderly Medicare-insured benefi-
ciaries. The sample included patients who were black or from poor com-
munities and who had been hospitalized for congestive heart failure,
pneumonia, acute myocardial infarction or stroke, in one of 297 acute care
hospitals urban teaching, urban nonteaching, or rural in five states
(Kahn et al., 1994~. The study is noteworthy for its detailed examination of
clinical records, and its use of explicit quality criteria to assess the most
basic (not luxury) elements of care: history taking and physical examina-
tion, common diagnostic tests such as chemistries and chest X-rays, and
standard therapies such as diuretics and antibiotics. Because the care of
black and poor patients was found to be similar, the two groups were
combined in the analysis. When the experience of these patients was com-
pared with that of people who were white or more affluent, the quality of
care as measured by these fundamental indicators was found to be sig-
nificantly lower for the black and poor group. While quality of care was
best in urban teaching hospitals, the magnitude of the quality gap was
similar in all three hospital types. The authors noted that further research
is necessary to clarify whether sociocultural and educational incongruity
between providers and patients translates into misunderstandings about
patients' preferences and expectations, and to evaluate the extent to which
stereotyping, discrimination and bias exist in the hospital setting. They
concluded that "racial characteristics and poverty status also influence
the quality of care received by acutely ill, insured patients after they have
gained access to the hospital."
A number of similar studies examined black-white differences in the
use of selected specific procedures. Lee and colleagues reviewed the use
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RACIAL AND ETHNIC DISPARITIES IN DIAGNOSIS AND TREATMENT 423
of both basic and sophisticated diagnostic tests and minor and major sur-
gical procedures, using claims data for Medicare beneficiaries in 10 states
and the District of Columbia who had both Part A and Part B coverage. A
subset of this sample was created by matching beneficiaries on the basis
of zipcode of residence to neutralize the effects of black-white differences
in provider access and regional practice patterns. Despite the adequacy of
health insurance coverage, black patients' utilization was substantially
weighted toward lower-cost procedures. The authors concluded that
"...providers appear to be giving less intensive care to otherwise similar
black Medicare beneficiaries" (Lee et al., 1997~. Similarly, McBean and
Gornick studied the use of 17 major diagnostic and therapeutic proce-
dures and found that black Medicare beneficiaries were much less likely
than whites to receive "referral-sensitive surgeries" (McBean and Gornick,
1994).
One of the largest studies reviewed more than 1.7 million hospital
discharge abstracts to examine use of major diagnostic and therapeutic
procedures in 77 disease categories in some 500 acute care hospitals
(Harris, Andrews, and Elixhauser,1997~. After controlling for patient age,
severity of illness, health insurance and hospital type, blacks were signifi-
cantly less likely than whites to receive a major therapeutic procedure in
almost half of the 77 disease categories. Again, in a five percent sample of
more than 1.2 million claims in a HCFA Medicare database, blacks were
found less likely than whites to receive 23 of 32 services, and the dispari-
ties were found even when patients were insured by both Medicare and
Medicaid, minimizing the confounding of race with financial barriers to
care (Escarce and Epstein, 1993~. In a study of racial variation in proce-
dures characterized as low, moderate or high physician discretion (Mort,
Weisman and Epstein, 1994), blacks were less likely to undergo even such
low-discretion (i.e., clinically urgent) procedures as appendectomy and
repair of an abdominal aortic aneurysm. Disparities are not limited to Af-
rican Americans, however. After adjusting for socioeconomic status, a
study comparing experiences of Hispanic with non-Hispanic patients in
California, Florida, and New York found that Hispanics were less likely
to undergo major procedures in 38 percent of 63 different disease catego-
ries (Andrews and Elixhauser, 2000~. A similar pattern was found even
when very basic in-hospital diagnostic and therapeutic procedures for
such common conditions as congestive heart failure and pneumonia were
examined (Ayanian et al., 1999a). Using explicit process criteria and after
adjustment, black Medicare patients were significantly less likely than
whites to receive adequate laboratory and other diagnostic tests or thera-
peutic drugs such as diuretics and antibiotics.
Most of the investigations described above are broad-brush studies.
Despite the consistency of their findings, and the indications that dispari-
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UNEQUAL TREATMENT
ties may occur at every level of disease severity and at every stage of the
diagnostic and therapeutic process, they have the limitations described
previously. Most are retrospective, and cannot report information
gleaned directly from providers or patients. Most have limited access to
detailed clinical records, and so estimates of variables such as stage and
severity of disease are likely to be approximations. There are serious prob-
lems in controlling or adjusting adequately for socioeconomic status when
data on individual patient income, education or occupation are limited or
absent. Health insurance may fail to eliminate the financial barrier of
out-of-pocket expenses, which may affect both patient and provider
choices. And finally, these studies offer relatively little evidence on out-
comes such as disability or subsequent mortality.
These limitations underlie both the wide range and tentative nature
of the explanations that are offered for the findings of racial and ethnic
differences in care. The list is extraordinarily varied, but strikingly similar
across studies. As noted previously, researchers suggest patient choice or
preference; unmeasured socioeconomic variables; unmeasured clinical
variables; unspecified sociocultural factors and differences in health be-
liefs; and impaired physician-patient communication and interactions.
Also frequently mentioned are financial barriers and procedure costs as
disincentives to care; differences in provider type, practice patterns, refer-
ral patterns and hospital resources; and overuse of procedures for whites
rather than underuse for blacks. Yet, almost all the investigators also raise
the possibility of racial bias and discrimination by providers, sometimes
referring explicitly to racial and ethnic stereotyping. And many call for
further research specifically designed to resolve the unanswered ques-
tions of causation.
A number of general surgical and orthopedic studies present similar
findings. Blacks hospitalized in Maryland from 1985 to 1987 had lower
rates for discretionary orthopedic, vascular, and laryngeal surgeries; the
more discretionary the procedure, the lower the incidence among blacks.
The differences were particularly marked for vascular surgery and were
attributed to lower rates of referral and access to specialty care (Gittelsohn,
Halpern, and Sanchez, 1991~. A large retrospective cohort study of ampu-
tation rates and leg-sparing surgery for peripheral vascular disease among
African-American and white Medicare beneficiaries found that among
both diabetics and nondiabetics, African Americans were significantly
more likely than whites to undergo amputations and significantly less
likely to receive lower-extremity arterial revascularization (Guadagnoli et
al., 1995~. A striking example of racially differential provision of advanced
technology was reported in the free-care VA system, in which both pro-
viders' financial incentives and patients' financial barriers are irrelevant
and the socioeconomic spectrum of patients is substantially narrowed.
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RACIAL AND ETHNIC DISPARITIES IN DIAGNOSIS AND TREATMENT 425
Researchers examining a prospective clinical records file covering all VA
hospitals with operating rooms studied the use of laparoscopic versus
conventional open cholecystectomy (which has a much higher in-hospital
death rate) in the first four years after the introduction of the newer
method. After adjustment for age, coexisting disease, socioeconomic sta-
tus, and potentially confounding clinical characteristics, African Ameri-
cans were 32 percent less likely than whites to receive laparoscopic sur-
gery (Arozullah et al., 1999~. In several other studies, African Americans
were significantly less likely to receive total hip or total knee replacements,
although racial variation in disease incidence may account for some of the
differences (Harris and Sledge, 1990; Wilson, May, and Kelly, 1994; Baron
et al., 1996~.
A few studies reported particularly troubling outcomes. Hispanic pa-
tients with long bone fractures in one teaching hospital emergency room
were twice as likely as non-Hispanics to receive no medication for pain
(Todd, Samaroo, and Hoffman, 1993~. At least one study showed that mi-
nority outpatients with cancer were provided with inadequate analgesic
medication (Cleeland et al., 1997~. Elderly African-American, Hispanic,
Native Americans and Asian nursing home residents with cancer were also
less likely to receive pain medication (Bernabei et al., 1998~. Finally, in a
national sample of intensive care units (ICUs) in the United States, African-
American patients were found to receive significantly less treatment, less
technological monitoring, fewer laboratory tests and less life-supporting
treatments than whites in the first 24 hours in the ICU, after adjusting for
type and severity of illness, age, and hospital characteristics (Williams et al.,
1995~. However, the researchers noted no black-white difference in overall
ICU and hospital death rates.
Finally, studies of hormone replacement therapy provide some in-
sight into the contribution of physician-patient communication to differ-
ences in care. Post-menopausal African-American women were not only
less likely than white women to receive such treatment, but also less likely
to receive counseling from physicians or be offered the choice of replace-
ment therapy (Marsh et al., 1999; McNagney and Jacobson, 1997; Ganeson
and Norris, 2000~.
Coronary Artery Disease
Coronary artery disease (CAD) and acute myocardial infarction (AMI)
are the most intensively and elaborately studied topics among all stud-
ies of racial and ethnic differences in care. In the last 20 years close to
200 studies, reviews, editorials and commentaries have investigated or
discussed disparities in cardiac catheterization, angioplasty, coronary ar-
tery bypass surgery (CABG) and medical therapies such as the use of
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UNEQUAL TREATMENT
Finally, the limitations of much of the research on disparities in race
and ethnicity underscore the need for prospective studies, with access to
detailed clinical records. This may be particularly important in under-
standing the variations in verbal and nonverbal physician-patient com-
munication in both race-concordant and race-discordant physician-patient
dyads. Further research is essential, but implementation of corrective rec-
ommendations now should not be held in abeyance.
The raw discrimination and blatant racism described by Myrdal
nearly six decades ago of relegating African Americans and other minor-
ity patients to all-black hospitals, charity wards, or the basement wards of
white hospitals have disappeared, but the scars of those past experiences
remain, and subtler forms of differential treatment have emerged (Myrdal,
1944~. As in other sectors of American society, the elimination of race/
ethnicity-based and class-based disadvantage in the health sector has al-
ways been an unsteady march, rather than a seamless record of uninter-
rupted progress. The documentation and further exploration of disparity
. . . . .
IS a step in an ongoing Journey.
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Representative terms from entire chapter:
ethnic disparities
