Unequal Treatment Confronting Racial and Ethnic Disparities in Health Care (2003) / Chapter Skim
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Racial and Ethnic Disparities in Healthcare: A Background and History W Michael Byrd, M.D., M.P.H.
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456 UNEQUAL TREATMENT disparities, including American racial, ethnic, and immigrant relations; "racism;" "historic racial discrimination" and bias; biased clinical decision-making; a health system structured on the basis of race, ethnicity, and class; and access barriers caused by shortages of racial and ethnic minority providers (Byrd and Clayton, 2000, 2002; Section of House Committee Report to Accompany H.R. 3064, 2000; Sullivan, 2000)
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457 RACIAL AND ETHNIC DISPARITIES IN HEALTHCARE It is clear that health and healthcare in the United States are multiracial, multi-ethnic, immigrant stories. A brief examination of racial and ethnic relations in this country from its colonial past to the present provides the context for the larger examination of health and healthcare as social processes and problems.
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458 UNEQUAL TREATMENT American Racial and Ethnic Relations: The Context Racial and ethnic diversity is a basic tenet in the evolution of this society. Neither health nor healthcare is an exception.
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459 RACIAL AND ETHNIC DISPARITIES IN HEALTHCARE under English common law, which became increasingly predominant in the colonies .
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460 UNEQUAL TREATMENT hibited the group as a whole (Brinkley, 1993; Feagin, 2000; Feagin and Feagin, 1999; Takaki, 1993)
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461 RACIAL AND ETHNIC DISPARITIES IN HEALTHCARE ous racial and ethnic groups in the United States, data must be collected with some type of category system. Although current data collection systems are both imprecise and do not adequately collect data for all the important U.S.
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462 UNEQUAL TREATMENT "Free Colored," with the latter term sometimes including detribalized Native Americans. Though the 1850 and 1860 censuses collected data for free persons in "White," "Black," or "Mulatto" categories, the main tables continued to designate the overall population as "White," "Slave," and "Free Colored." The 1860 census also counted "Civilized Indians" (who were required to pay taxes because they did not live on reservations)
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463 RACIAL AND ETHNIC DISPARITIES IN HEALTHCARE istic democratic society, the ethnic-origin category was introduced in the Current Population Survey in 1969 and included in the U.S. Census in 1980.
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464 UNEQUAL TREATMENT science of tracking racial and ethnic health and healthcare outcomes, urgent efforts should be directed toward eliminating racial and ethnic bias in the caregivers and re-educating both caregivers and patients to eliminate stereotyping, conscious, and unconscious biases. In the interim, there can be no delay in making recommendations leading to: 1)
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465 RACIAL AND ETHNIC DISPARITIES IN HEALTHCARE cussion (Byrd and Clayton, 2000, 2001a, 2002; Fluss, 1997; Garrett, 2000; Malone and Johnson, 1986; U.S. Commission on Civil Rights, 1999a, 1999b)
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466 UNEQUAL TREATMENT TABLE 1. Race, Ethnicity, and Immigration: North American Health and Health Care Selected Indigenous and Immigrant Groups: An Overview of Race, Ethnicity, and Immigration in Relationship to Health and Health Care in North America Indigenous and Economic Conditions Governme Immigrant Group Time of Entry in North America and Action Phase One: Pre-Columbian and North American Development: Prehistory-1600s Native Americans– Prehistory-1600– Land-based, self-sufficient, local economies Indigenous Group 2002 with some regional trade; Ranged from Pueblo agriculturalists of Southwest, hunting societies on the Plains, to mixed agricultural-hunting societies elsewhere; Autonomous bands and tribes of geo graphically isolated, discrete, hunter gath erer, and farming communities.
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467 RACIAL AND ETHNIC DISPARITIES IN HEALTHCARE alth and Government Conditions Some Health and and Actions Health Care Considerations Autonomous tribal units based on Benign New World health environment: chiefdoms, common land-ownership, and virtually no exposure to infectious crowd mutually supportive living conditions. diseases; Slower pace of city development; Government participation in land take- and high levels of population isolation overs, broken treaties, and traumatic relo- compared with Old World.
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468 UNEQUAL TREATMENT TABLE 1. (Continued)
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469 RACIAL AND ETHNIC DISPARITIES IN HEALTHCARE Government Conditions Some Health and and Actions Health Care Considerations Government backing for labor recruitment; Initially assigned to lower tiers of health U.S. treaties with Europe; incoming num- system (public hospitals, dispensaries, bers reduced by 1924 Immigration Act.
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470 UNEQUAL TREATMENT 1900, only about 250,000 Native Americans remained in the United States (Pedraza and Rumbaut, 1996)
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471 RACIAL AND ETHNIC DISPARITIES IN HEALTHCARE marginal populations (Byrd and Clayton, 2000; Feagin, 2000; Vogel, 1980, 1985)
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472 UNEQUAL TREATMENT On one level, the late nineteenth century represented an era of reconciliation and progress for white European American ethnic groups -- both the North and South -- as the United States emerged as a world power. However, traditional patterns of racial and ethnic oppression and conflict between dominant White, Anglo-Saxon, Protestant groups, and nonEuropean as well as more recent immigrant groups (e.g., Italians and Jews)
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473 RACIAL AND ETHNIC DISPARITIES IN HEALTHCARE between America's racial and ethnic minorities and the European American majority narrowed over the first three-fourths of the twentieth century. Though overall U.S.
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474 UNEQUAL TREATMENT tics, group interactions, power relationships and experiences juxtaposed with a changing capitalistic economy and expanding political and governmental framework -- Table 1) provides a backdrop that clarifies the immigrants' health status and outcomes and evolving relationships with and within the health system (Byrd and Clayton, 2000, 2001a, 2002; Diamond, 1999; Feagin, 2000; Feagin and Feagin, 1999; Garrett, 2000)
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475 RACIAL AND ETHNIC DISPARITIES IN HEALTHCARE power and economic means that are built into the status system by formal and informal, structural, and to some extent, legal norms. The fact that individual class system mobility is also limited and that experiences differ markedly for certain groups is also based on understanding that there are two very different patterns of ethnic incorporation -- discrimination versus exclusion.
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476 UNEQUAL TREATMENT 35,470,000 as of January 2, 2001, or 12.8 percent of the U.S. population (Bohannan and Curtin, 1995; U.S.
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477 RACIAL AND ETHNIC DISPARITIES IN HEALTHCARE Based on the latest available data as the new millennium began, African Americans are faced with persistent or worsening, wide and deep, racebased health disparities compared with either the white or the general population (Byrd and Clayton, 2000, 2001a, 2002; Clayton and Byrd, 2001; Collins, Hall, and Neuhaus, 1999; Mayberry, Mili, and Ofili, 2000; Williams, 1999)
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478 UNEQUAL TREATMENT Moreover, "Health care for the Amerindian population had been poorly provided by the Bureau of Indian Affairs since 1849" (Porter, 1999, 288)
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479 RACIAL AND ETHNIC DISPARITIES IN HEALTHCARE akin to those of American Indians/Alaska natives rather than to other Asian subpopulations. Disaggregating their health status and outcomes from other Asian subpopulations whenever possible would seem to lend clarity to any health assessments or analyses of such arbitrarily combined groups (Feagin and Feagin, 1999; Office of Research on Women's Health, 1998; U.S.
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480 UNEQUAL TREATMENT the Republic of Belau and the Federated States of Micronesia have older hospitals and provide a generally poorer level of care. Though the health problems of the Native Hawaiians and other Pacific Islander groups today largely reflect their poor socioeconomic and educational status, whether in island or urban settings, barriers to health and healthcare such as linguistic isolation, cultural differences (e.g., obesity is acceptable in Polynesian culture and large body size is equated with power and respect)
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481 RACIAL AND ETHNIC DISPARITIES IN HEALTHCARE graphical and cultural components. Although their origins are predominantly Native American (Indian)
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482 UNEQUAL TREATMENT lower rates of hypertension than Cuban, white, or African-American women. Among Hispanics, Puerto Rican and Cuban Americans use health facilities at rates comparable with whites while overall group utilization rates are lower.
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483 RACIAL AND ETHNIC DISPARITIES IN HEALTHCARE Feagin, 2000; Feagin and Feagin, 1999; Starr, 1982; U.S. Census Bureau, 2001b)
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484 UNEQUAL TREATMENT less, they are the leading edge of medical and health establishments and are a strong determinant of the "norms" for health and healthcare in America (Byrd and Clayton, 2000, 2002; Dowling, 1982; Starr, 1982; Stevens, 1971)
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485 RACIAL AND ETHNIC DISPARITIES IN HEALTHCARE Irish Americans Separate branches of the same nationality, Irish Catholic and ScotchIrish Americans total about 11 percent of the population. They represent the second (39 million)
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486 UNEQUAL TREATMENT slower to yield their distinctive ethnic identity. Having endured poverty, difficult working conditions, anti-Catholic prejudice, and intense nativist attacks along with the poor health status and outcomes associated with those conditions, Italian Americans finally shrugged off the "inferior race" imagery and have made rapid progress up the political, social, and economic ladder, especially after World War II.
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487 RACIAL AND ETHNIC DISPARITIES IN HEALTHCARE Dutch, Scottish, Swedish, and Norwegians sometimes experienced acculturation trauma and discrimination barriers to their entry into American society and the health system. In the 1960s, President John F
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488 UNEQUAL TREATMENT persist .
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489 RACIAL AND ETHNIC DISPARITIES IN HEALTHCARE tained in Byrd and Clayton's database at the Harvard School of Public Health and their book, An American Health Dilemma.* Virtually all of the data suggest that from the United States' beginnings, even before the Revolutionary War, black, poor, Native American, and immigrant populations suffered the worst health status, outcomes, and healthcare.
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490 UNEQUAL TREATMENT CHANGING CONCEPTS OF RACE AND ETHNICITY On Racial Groups and Hierarchies In contrast to ethnicity, race is a concept with roots stretching back to antiquity. The Feagins' (1999, 6)
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491 RACIAL AND ETHNIC DISPARITIES IN HEALTHCARE progressive elimination of the term and concept of race from textbooks...in the United States .
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492 UNEQUAL TREATMENT Racism is any set of beliefs that organic, genetically transmitted differ ences (whether real of imagined) between human groups are intrinsi cally associated with the presence or the absence of certain socially rel evant abilities or characteristics, hence that such differences are a legitimate basis of invidious distinctions between groups socially defined as races (Van den Berghe, 1967, 11)
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493 RACIAL AND ETHNIC DISPARITIES IN HEALTHCARE medical ethical, and American creed issues that burden our society and health system as we enter the twenty-first century; 5. Understanding the basic human psychological mechanisms, regardless of who the perpetrators or victims may be, that produce racism, bias, stereotyping, discrimination, and group hatreds that might affect clinical decision-making is critical to crafting strategies and interventions for solving the problems; and 6.
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494 UNEQUAL TREATMENT mediators include: 1) Power, the unfair distribution or disproportionate capacity by the dominant white/Anglo group to make and enforce decisions; 2)
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495 RACIAL AND ETHNIC DISPARITIES IN HEALTHCARE police profiling wherein African Americans are automatically criminal suspects; the racism of "reverse discrimination" whereby white males are "protected" by Civil Rights laws that were designed to help blacks who were previously denied participation in American society; and the racism of computerized arrest record files for job screening in neighborhoods where most of the black adolescent males experience police encounters (whether convicted of crimes or not)
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496 UNEQUAL TREATMENT scholars like Nathan Glazer and Thomas Sowell, race in America has not been the same as ethnicity" (1993, 10)
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497 RACIAL AND ETHNIC DISPARITIES IN HEALTHCARE are longstanding foci of bias, inequity, and inequality. In addition, only brief allusions to the broader historical or social contexts are possible; our examination will be limited to Western and, later, American medicine, health, and healthcare; and class dimensions will automatically creep in.
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498 UNEQUAL TREATMENT advantaged from medical care and "normalizing" the medical profession as a socially distant upper-class activity (Byrd and Clayton, 2000; Goldberg, 1990; Veatch, 1981)
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499 RACIAL AND ETHNIC DISPARITIES IN HEALTHCARE and lower quality healthcare for slaves and nonwhite people (Byrd and Clayton, 2000; Finley, 1983; Lewis, 1990; Sanders, 1978)
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500 UNEQUAL TREATMENT sification, which appeared in several editions after 1735. Both used skin color as major classification criteria and both marginalized blacks, the former as a different species (Davis, 1966, 454; Marshall and Williams, 1982, 242-243)
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501 RACIAL AND ETHNIC DISPARITIES IN HEALTHCARE The Colonial, Republican, Jacksonian, and Antebellum Periods In the rapidly evolving medical and scientific communities during the American Colonial, Republican, Jacksonian, and Antebellum periods between 1619 and 1861, scientific racism burgeoned. As Reed pointed out, before the twentieth century "Scientific racism was not ‘pseudoscience' but an integral part of the intellectual world-view that nurtured the rise of modern biology and anthropology" (1989, 1358)
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502 UNEQUAL TREATMENT providers, to the field soldiers on the battlefields. In lieu of the generalized improvements in medicine, public health, and health services as a result of the Civil War, higher African-American mortality rates and poorer health outcomes reflected another set of realities -- black social and economic collapse; health segregation, discrimination, and exploitation at all levels throughout the Civil War, Reconstruction, Gilded Age, and Progressive eras; collapse of the slave health subsystem; and refusal by the mainstream health system to incorporate Freedmen (Barbeau and Henri, 1974; Byrd and Clayton, 2000; Cobb, 1952; Cornish, 1966; Duffy, 1990; Rabinowitz, 1978)
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503 RACIAL AND ETHNIC DISPARITIES IN HEALTHCARE traditions and institutions (Byrd and Clayton, 1992, 2000; Cobb, 1981; Morais, 1967)
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504 UNEQUAL TREATMENT class, and ethnic biases, prejudices, and inequities in the health system, often shifting issues such as poverty, insanity, imbecility, and congenital malformations, in attempts to divorce them from areas of social concern, into the domain of healthcare under the aegis of so-called scientific dispensation. So-called scientific data such as family trees and IQ tests were used to justify sterilization, incarceration, and immigration restriction.
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505 RACIAL AND ETHNIC DISPARITIES IN HEALTHCARE grants, blacks, the impoverished or the mentally challenged while the Negro medical ghetto continued to grow in size and complexity (Cobb, 1947, 1948, 1981; Gamble, 1995)
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506 UNEQUAL TREATMENT series of desegregation lawsuits won against segregated medical schools and hospitals, and a series of Imhotep Hospital Integration conferences that took place between 1957 and 1964, which ultimately led to desegregated hospitals (Beardsley, 1987; Byrd and Clayton, 1992, 2000, 2002; Cobb, 1981; Cray, 1970; Morais, 1967; Smith, 1999)
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507 RACIAL AND ETHNIC DISPARITIES IN HEALTHCARE A Retrenchment Era in Healthcare After the legislative defeat of the AMA and the mainstream system in 1965 with the passage of Medicare and Medicaid and a short period of being held at bay, mainstream resistance to reform of the system continued unabated. Retrenchment after 1975 consisted of unaddressed health system structural segregation, discrimination, and institutional racism; continued ethnic, class, gender, cultural segregation and discrimination in health and the health system; stagnation or deterioration of health status and outcomes for blacks and the poor; steep cuts in public funding for healthcare; and complicity in non-enforcement of civil rights laws and regulations (Byrd and Clayton, 1992, 2000, 2001b, 2002; Campion, 1984; Cobb, 1981; Morais, 1967; Smith, 1999)
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508 UNEQUAL TREATMENT and inequalities, origins almost four centuries old, health insurance crisis) formed what was in reality a "dual health crisis in black and white" (Byrd and Clayton, 2000, 2002; Clayton and Byrd, 1993b, 2001; U.S.
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509 RACIAL AND ETHNIC DISPARITIES IN HEALTHCARE five centuries old and the latter nearly four centuries old. Both groups' health experiences parallel their citizenship and social status in many respects.
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510 UNEQUAL TREATMENT had on individual and population health. And that debate, coupled with social exclusions from the health system .
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511 RACIAL AND ETHNIC DISPARITIES IN HEALTHCARE Blakely RL, Harrington JM, eds.
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512 UNEQUAL TREATMENT Canedy D
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513 RACIAL AND ETHNIC DISPARITIES IN HEALTHCARE Davis K, Lillie-Blanton M, Lyons B, Mullan F, Powe N, Rowland D
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514 UNEQUAL TREATMENT Flexner A
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515 RACIAL AND ETHNIC DISPARITIES IN HEALTHCARE Haynes MA, Smedley BD, eds.
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516 UNEQUAL TREATMENT Kozol J
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517 RACIAL AND ETHNIC DISPARITIES IN HEALTHCARE National Center for Health Statistics.
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518 UNEQUAL TREATMENT Ransford O
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519 RACIAL AND ETHNIC DISPARITIES IN HEALTHCARE Sidel VW, Sidel R, eds.
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520 UNEQUAL TREATMENT Trennert RA.
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521 RACIAL AND ETHNIC DISPARITIES IN HEALTHCARE Viner, Russell.
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522 UNEQUAL TREATMENT to three generations, moves toward the dominant Anglo-Protes tant culture.
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523 RACIAL AND ETHNIC DISPARITIES IN HEALTHCARE Actions carried out by members of dominant groups, or DISCRIMINATION their representatives, that have a differential and harmful impact on members of subordinate racial or ethnic groups. DOMINANT GROUP A racial or ethnic group with the greatest power and resources in a society (also called a majority group)
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524 UNEQUAL TREATMENT custom, practice, and law, so there need not be an identifiable per petrator. It is often evident as inaction in the face of need.
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525 RACIAL AND ETHNIC DISPARITIES IN HEALTHCARE institutions and social structures, a shared worldview, and social myths; 2. A term developed in the 1700s by European analysts to refer to what is also called a racial group (see racial group)
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526 UNEQUAL TREATMENT irrelevant outside those contexts. The medical profession and health system are excellent examples of subcultures (see culture)
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527 RACIAL AND ETHNIC DISPARITIES IN HEALTHCARE Van den Berghe PL.
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