Does either color or sex determine the level and frequency of medical care that individual patients receive? A careful look at available data, the author argues, suggests that the answer is no.
WITH increasing frequency social activists, scholars, and even health-care professionals assert that the culture of medicine (indeed, culture itself) is to blame for many illnesses. They are not talking about health-insurance woes, fifteen-minute office visits, or medical mistakes. They are making a far more sweeping, and more radical, argument.
An article in The New England Journal of Medicine in February of 1999 reported that white men get the best treatment for heart disease. Other experts have cited discrimination in patient care as a cause of disparities in the health of blacks and whites.
The 1998 President’s Initiative on Race stated, “Research suggests that discrimination and racism create stress leading to poorer health among members of racial minority groups.” Some public-health experts who advance this claim have used it to rebut physicians who urge people to take responsibility for protecting their own health.
Women’s-health advocates often contend that the maledominated medical establishment has kept women from participating as subjects in research studies, thus depriving them of the benefits of medical breakthroughs. Some nurses say that they are oppressed by the hierarchical nature of that medical establishment and thus prevented from giving the best care to patients.
Former psychiatric patients, calling themselves “consumer– survivors,” condemn the health-care system for violating their human rights. They are on a crusade to “limit the powers of psychiatry by making consumers full partners in diagnosis and treatment.”
The common theme here is the failure of the medical system to make a connection between illness and oppression. This is not a dry academic debate with purely abstract consequences. The critics are beginning to fashion a world of politically correct medicine. I began to worry about this in 1995, when I learned that some of my fellow psychiatrists at San Francisco General Hospital were grouping inpatients according to race and sexual orientation so that they could organize treatment around psychological needs supposedly specific to those groups.
Though activists believe they are fighting for better health through social justice, their actions do not necessarily prevent disease, treat symptoms, or improve clinical methods. At best they create distractions and waste money; at worst they interfere with effective treatment. In either case, they undermine the Hippocratic ideal, which puts the patient first.
How did these activists-I call them “indoctrinologists,” because their diagnosis is oppression and their prescription is social reform-manage to gain their foothold? Larger social trends supply part of the answer: for several decades a range of institutions, such as universities, courts, and workplaces, have been under assault by people claiming oppression of one sort or another. Another part of the answer resides in well-earned feelings of guilt that afflict the medical profession. The reputation of the U. S. Public Health Service is still tarnished by revelations about the notorious syphilis study in Tuskegee, Alabama. For years women were expected to submit without question to radical mastectomies and hysterectomies simply because their (male) doctors recommended them. Psychiatry has its own embarrassments, such as the dismal back wards of state mental hospitals in the 1930s, 1940s, and 1950s.
When the control of communicable diseases was the primary focus of public health, the profession’s tasks were well defined-tracking disease and ensuring the purity of food and water supplies-and its victories were often dramatic. Today public health is still very much concerned with epidemiology (the study of diseases in populations) and the control of infections, but over the past century its scope has expanded, legitimately so, to include such activities as monitoring air quality, administering vaccination programs and community-based clinics, and combating asthma, diabetes, heart disease, and other chronic conditions.
Not surprisingly, public health has inevitably overlapped with public policy. After all, many diseases and afflictions are directly related to living and working conditions. In Colonial times, for example, local governments passed sanitation laws and imposed fines for selling putrid meat or failing to drain swamps. In the early part of the twentieth century the “industrial hygiene” movement played an important role in public health by condemning the needlessly hazardous working conditions of coal miners, factory hands, and other laborers, which could result in severe injuries, lung disease, or poisoning from mercury, radium, or solvents. The movement recalled the spirit of the nineteenth-century German pathologist, physician, and statesman Rudolf Virchow, who had spoken eloquently about the effects of social conditions such as poverty and squalor on fitness and health. He called physicians the “natural attorneys of the poor.”
Documenting the unhealthful effects of social conditions and calling them to the attention of civic leaders is one thing-but some contemporary public-health experts have gone much further.
CAN RACISM MAKE YOU SICK?
IN the early 1990s a new academic enterprise, “social production theory,” was born. Many scholars consider Richard G. Wilkinson, a professor of social epidemiology at the University of Sussex, in England, to be the father of this school of thought, which considers how social variablesamong them classism, racism, and sexism-may contribute to disease. Wilkinson published an article on the relationship between income and health in 1992, and numerous studies followed. Social productionism posits two general ways in which social disenfranchisement can lead to infirmity and a shortened life expectancy: through the stress of oppression, and through relative material disadvantage and inferior access to health care, which take the greatest toll on minorities and the poor.
We know that, on average, people who are low on the socioeconomic ladder are less healthy and do not live as long as those above them. But is a person’s health largely at the mercy of social forces? Some public-health experts come close to saying yes. Rodney Clark, a psychologist at Wayne State University, asserts that emphasizing the role of personal responsibility in various areas, including health, constitutes “subtler forms of racism” than overt discrimination. Richard S. Cooper, a physician at Loyola University Medical School, near Chicago, holds a similar view. “For all intents and purposes,” he writes, “black people in this society are imprisoned by institutional racism; this is the attribute of blackness which at bottom determines their health status.”
Hypertension, or high blood pressure, is more likely to afflict black Americans than white, even when factors such as income and salt intake are taken into account. Several explanations have been offered-chief among them diet and genetic predisposition-but the issue has continued to perplex medical researchers.
In the fall of 1996 Nancy Krieger, of Harvard University’s School of Public Health, and her colleague Stephen Sidney, a physician at the Kaiser Foundation Research Institute, in Oakland, California, claimed to have new insight into the blood-pressure puzzle: that blacks are often victims of racial bias, they said, could explain their higher levels of hypertension. Krieger and Sidney’s study, “Racial Discrimination and Blood Pressure,” appeared in the American Journal of Public Health, and it made news instantly.
“DISCRIMINATION MAY CAUSE HYPERTENSION IN BLACKS,” a headline in The Washington Post for October 24, 1996, declared. On the same day National Public Radio broadcast a report in which one psychologist interviewed about the study said, “We’re having more hard, concrete data that what society does to you can affect your health.” Brent Staples, of The New York Times, wrote an editorial the following month titled “Death by Discrimination?” A couple of years later, still mindful of the study, Staples wrote, “The medical profession has yet to list ‘racism’ as a cause of death. But some social scientists now see tension related to discrimination as a health hazard on par with smoking and a high-fat diet.” Krieger and Sidney’s study was included in the 1998 report from President Clinton’s Initiative on Race.
It is not unreasonable to think that the stress of being a victim of discrimination could produce certain kinds of illnesses. After all, we know that many physiological processes are influenced by psychological stress. For example, the immune and hormonal systems and cardiovascular functioning can be affected by emotional states.
In their study Krieger and Sidney collected information on 4,086 black and white men and women aged twenty-five to thirty-seven, who were questioned about their “experiences of racial discrimination and unfair treatment.” The researchers asked whether the subjects had ever “been prevented from doing something [for example, getting a job or securing housing] or been hassled or made to feel inferior” because of any of a number of social variables, including sex and race. They divided the subjects into male and female, black and white, working-class and professional, and also into three groups according to the number of episodes of racial discrimination each had experienced: none, one or two, or three or more. Risk factors for high blood pressure such as obesity and smoking were taken into account. (The researchers did not factor in salt intake, however, which is a major determinant of blood-pressure levels, particularly in African-Americans.)
Krieger and Sidney looked at blood-pressure readings to see if a correlation could be found with the subjects’ experiences of bias. They assumed that incidents the subjects perceived as discriminatory produced equal amounts of stress on all of them.
The results did not seem to follow any obvious pattern. Black working-class men and black working-class women who had reported no episodes of discrimination had higher blood-pressure readings than those who had reported one or more. Black professional women who had reported one or two episodes of discrimination had lower blood-pressure readings than those who had reported none or three or more, and black professional men who had reported one or two episodes of discrimination had higher readings than those reporting none or three or more.
Krieger and Sidney also asked their subjects how they had responded to being treated unfairly. Again, the findings seemed to show no consistent pattern. The highest blood-pressure readings among black working-class women were found in those who accepted unfair treatment as a fact of life and did not talk about it. Among black professional men, those who accepted unfairness as a fact and kept their experiences to themselves had lower blood pressure than those who did something about it and talked to others. As an explanation for the varying results, Krieger and Sidney considered the possibility that “some people who experience discrimination may not acknowledge or report it as such” or “may find it painful to admit that they have experienced discrimination.” They also considered the idea that the subjects felt they deserved to be discriminated against, owing to their race-a process called internalized oppression.
Thus any finding that did not fit the expected direction of the data could be explained away. It is a standard rule of research that hypotheses must survive attempts to falsify them before they can be regarded as true-or, more precisely, as highly probable. But internalized oppression, by its very nature, is difficult to falsify-and the researchers seemed to make no attempt to test this hypothesis. Nonetheless, they confidently concluded, “Our results indicate that racial discrimination shapes patterns of blood pressure among the U. S. Black population.”
RACE AND MEDICAL BIAS
ACCORDING to indoctrinologists, a mismatch in race between doctor and patient-especially when the doctor is white and the patient is not-may be enough to trigger biases that result in second-rate medical treatment and poorer health. Kenneth DeVille, of the Department of Medical Humanities at the East Carolina University School of Medicine, wrote in the August, 1999, issue of The American Journal of Public Health, “It is increasingly evident that African Americans and other minority patients have strong grounds for doubting both the goodwill and the color blindness of White medical practitioners.” The American Medical Association’s official newspaper, American Medical News, has stated that “a growing body of research reports that racial disparities in health status can be explained, at least in part, by racism and discrimination within the health care system itself.” This is why, according to the Reverend Al Sharpton, of New York, health is the “new civil-rights battlefront”-a sentiment echoed by other African-American leaders, including the Reverend Jesse Jackson and Julian Bond, the chairman of the National Association for the Advancement of Colored People.
In a 1998 radio address delivered during Black History Month, President Clinton said, “Nowhere are the divisions of race and ethnicity more sharply drawn than in the health of our people.” Infant-mortality rates were twice as high for African-Americans as for whites, he said. Black men suffered from heart disease at nearly twice the rate of whites, and blacks were more likely than whites to die from breast cancer or prostate cancer. Overall, African-Americans were less likely to be routinely screened for cancer and less likely to get regular check-ups. Perhaps, the President said, one of the reasons for these disparities was “discrimination in the delivery of health services.”
Given the history of systematic racial discrimination and segregation in the health-care system, lingering bias shouldn’t be categorically ruled out. Black patients were once treated in separate and inferior hospital wards-a policy that persisted at many hospitals in the Deep South until the 1960s. Routinely barred from joining hospital staffs and medical societies, black physicians started their own institutions to treat other blacks. As late as the mid-1960s several medical schools had restrictions against admitting black students.
Leslie Pickering Francis, a medical ethicist at the University of Utah, argues that in the absence of contrary evidence, “racism remains the presumptive cause of… health care problems minorities face.” This view is increasingly common. But the available evidence suggests that many race-related differences in health are not what they seem.
Cardiac catheterization, a procedure used to detect blockage in the coronary arteries (the vessels that feed blood to the heart itself), is frequently crucial in determining whether the arteries can be widened using a tiny balloon (a process known as balloon angioplasty) or whether some or all of them must be replaced in a bypass operation. Struck by the observation that black patients undergo catheterization less often than whites, Kevin A. Schulman, then at Georgetown University Medical Center, and others wanted to examine how doctors make the decision to refer patients for the procedure. They recruited 720 primary-care physicians at medical conventions and asked them to participate in a study of clinical decisionmaking. The physicians were not told that one purpose of the study was to explore how the race and sex of a patient might affect decisions, or that the researchers expected to find African-Americans and women referred for cardiac catheterization less frequently than white men.
The participants, most of whom were white, each watched one randomly selected video of a patient (actually, an actor wearing a hospital gown) who answered questions about chest pain and other relevant medical history. The viewers were given fictitious information about the actor-patients’ insurance, occupations, and other personal history. The questions asked and the actors’ responses, down to the gestures used when describing their symptoms, were all scripted to minimize inconsistencies. There were eight actors-representing all the possible combinations of race (black or white), sex (male or female), and age (fifty-five or seventy)-and 144 scenarios, one for every combination of these variables plus clinical variables: the nature of the chest pain, the level of coronary risk, and stress-test results.
The participants were asked whether the patients’ complaints appeared to reflect heart disease or another kind of distress, such as indigestion, and to rate the likelihood that the patient had coronary-artery disease. According to the study, 11 women and blacks [in the study] were less likely to be referred for cardiac catheterization than men and whites.” Men and whites were not referred about nine percent of the time; women and blacks were not referred about 15 percent of the time.
Schulman and his colleagues used a statistical analysis called odds ratio to report their findings-the ratio of the odds in favor of blacks’ being referred for catheterization to the odds of whites’ being referred. The odds that blacks would be referred were 40 percent lower. Odds ratio is not the same as risk ratio, but the media equated them in referring to this study and reported that blacks had a 40 percent lower referral rate than whites. The statistic was widely circulated, and in discussing odds ratio, Schulman said in a Nightline interview the day before the study was published that “blacks were 40 percent less likely to be referred for cardiac catheterization compared to whites.”
The study findings were presented in an article titled “The Effect of Race and Sex on Physicians’ Recommendations for Cardiac Catheterization,” published in The New England Journal of Medicine in February of 1999. Schulman and his colleagues wrote,
Our finding that the race and sex of the patient influence the recommendations of physicians independently of other factors may suggest bias on the part of the physicians. However, our study could not assess the form of bias. Bias may represent overt prejudice on the part of physicians or, more likely, could be the result of subconscious perceptions rather than deliberate actions or thoughts. Subconscious bias occurs when a patient’s membership in a target group automatically activates a cultural stereotype in the physician’s memory regardless of the level of prejudice the physician has.
The study received wide attention. On ABC’s World News This Morning, Juju Chang told viewers, “How your doctor treats your heart may depend on the color of your skin…. The bias shows up in the diagnosis and doctors don’t even realize it.” Peter Jennings predicted on World News Tonight that the study would make “political waves” because it showed that “prejudice among doctors causes a gap in the quality of health care between blacks and whites.” On Nightline, Ted Koppel set up the story like this: “Last night we told you how the town of Jasper, Texas, is coming to terms with being the place where a black man was dragged to his death behind a truck by an avowed racist. Tonight we’re going to focus on [doctors] … who would be shocked to learn that what they do routinely fits quite easily into the category of racist behavior.”
Five months after the study appeared, The New England Journal of Medicine published a rebuttal, by Lisa M. Schwartz, Steven Woloshin, and H. Gilbert Welch, all physicians at the White River Junction Veterans Administration Hospital, in Vermont. The authors reviewed the original study data and explained that the actual average referral rates for three of the four groups were in fact the same. White men, white women, and black men were all referred by about nine out of ten doctors; black women were referred by about eight out of ten.
Schwartz, Woloshin, and Welch also expressed dismay that Schulman and his colleagues had focused discussion on two groupings (race and sex) rather than on the breakdown into four groups-white men, black men, white women, and black women-and that odds ratios were used in the study but reported by the media as risk ratios, thus overstating the findings. Equating odds ratios with risk ratios led to the “mistaken impression that blacks had a 40 percent lower probability of referral than whites, whereas in fact, the probability of referral for blacks was 7 percent lower,” the authors wrote. “. . . These exaggerations serve only to fuel anger and undermine the trust between physicians and their patients.” Schwartz and her colleagues were not alone in expressing concern; the NEJM editors published a note in the same issue expressing regret that odds ratios were used when risk ratios would have been clearer. “We take responsibility for the media’s overinterpretation of [this] article,” they wrote. “The evidence of racism and sexism in [the Schulman] study was overstated.”
Nevertheless, Schulman persisted. “Our study will … encourage the medical profession to seek ways to eliminate unconscious bias that may influence physicians’ clinical decisions,” he maintained in The New England Journal of Medicine. Schulman also met with the Congressional Black Caucus, at its invitation, and briefed members on bias in the health-care system. Paul Douglass, a cardiologist with the Morehouse School of Medicine, in Atlanta, supports Schulman’s interpretation. “You can argue with statistics all day,” he told USA Today. “We have to face the reality of our situation: there is a gender and racial bias.”
ALTERNATIVE EXPLANATIONS
LESS eye-catching than accusations of bias are everyday aspects of clinical care that account for many of the recorded disparities among patient groups. For example, medical problems do not necessarily occur with the same frequency across races. As a 1999 report from the Henry J. Kaiser Family Foundation points out, “It should be noted that every differential in care is not necessarily a problem and the level of care obtained by whites may not be the appropriate standard for comparison.” Consider these facts: uterine fibroid tumors and hysterectomies are more common in black women than in white women, and osteoporosis-related fractures, and thus hip replacements, are rarer. Limb amputation is more common among black patients, sometimes because thicker atherosclerosis in the leg makes it harder to perform limb-saving surgery.
African-Americans suffer strokes at higher rates than whites, yet the former are much less likely to undergo carotid endarterectomy, a procedure to unclog arteries in the neck. Racism? Unlikely. Whites tend to have obstructions in the large, superficial carotid arteries of the neck region, which are readily accessible to surgery, whereas blacks often have blockages in the branches of the carotids. These smaller vessels run deeper and farther up into the head, where surgery is riskier.
Thus even without cultural or socioeconomic obstacles an African-American patient at high risk for stroke is far less likely than a white patient to undergo carotid endarterectomy. Yet David R. Williams, a sociologist at the University of Michigan’s Institute for Social Research, perceives disparities like these as evidence of bias. American Medical News quoted Williams in May of last year:
National studies, such as one that examined care at Dept. of Veterans Affairs medical facilities-where all of the patients have comparable insurance coverage-suggest “racial disparities in the quality of medical care do not merely reflect the behavior of a few bad apples,” Williams said. “The evidence is too overwhelming and the pattern is too pervasive.”
Williams and others seem not to consider a different interpretation: the patients’ clinical needs, rather than the doctors’ personal biases, are dictating the care. If not for concern about their patients (many of whom are treated in private hospitals and have health insurance), why wouldn’t physicians perform a procedure for which they would be paid?
Indoctrinologists are making steady inroads in medicine. They now sit at the helms of professional associations and hold impressive posts at schools of public health; they have changed medical-school admissions criteria; they serve on the boards of respected academic journals. They are outspoken, sometimes insistent participants in many legislative and political debates. Their numbers and influence are growing. Most disturbing, I find, is their stubborn reluctance to acknowledge that each person has some responsibility for preserving his or her own health-an attitude that threatens to reverse the gains made by public health in the past century.
I am by no means the first to note the existence of the indoctrinologists. The medical economist Robert G. Evans commented in Why Are Some People Healthy and Others Not? (1994), “For [those on the left], health differentials are markers for social inequality and injustice more generally, and are further evidence of the need to redistribute wealth and power, and restructure or overturn the existing social order.” An example of what Evans is talking about comes from Sally Zierler, of Brown University’s Department of Community Health, who sees AIDS as “a biological expression of social inequality.” At a lecture Zierler gave at the 1998 annual meeting of the American Public Health Association, I copied down some of her recommendations for changing the wage structure, which is one of her prescriptions for curbing the AIDS epidemic: cap salaries of CEOs, eliminate corporate subsidies, and strengthen labor unions.
Tuberculosis is another disease that one might call a biological expression of social inequality, because it primarily affects the poor, the homeless, and the addicted. Yet it was New York City’s hard-nosed decision, in the early 1990s, to require that everyone who needed medication take it daily, in front of a health worker, that checked the spread of tuberculosis.
Ironically, indoctrinologists, who want revolution in the name of health, have been quick to condemn practical hygiene efforts as dangerous social intrusion. As Paul Starr noted in his sweeping history The Social Transformation of American Medicine (1982),
The recent anti-Progressive historians, including both Marxists and liberals, tend to reclassify as social control events like the conquest of disease that were once properly regarded as historic achievements of human freedom. They remember the public health nurse who instructed mothers in infant hygiene as a kind of surreptitious agent of the police, insinuating bourgeois ideals into the authentic culture of the working class.
Some of the more counterproductive manifestations of this revolution-in-waiting can be reversed overnight. I suggest, for example, that the federal government cease funding research into the effects of “powerlessness,” “classism,” and “racism” on health; these are virtually impossible to study in quantitative fashion. I also think that medical schools should stop using racial preferences in admitting students, in light of ample evidence that students admitted noncompetitively have academic trouble in medical school and little evidence that minority patients fare better when treated by minority physicians-a standard justification for racial preferences.
These steps would be a good beginning, but they are unlikely to halt a movement of such broad scope. We must remain clear-eyed about the fact that uneven access to medical services, disparate knowledge of good health practices, and patients’ own attitudes about their health-not discrimination and bias-underlie the vast majority of differences in health outcomes. Moreover, we must concentrate on the problems that the health-care profession can actually do something about: preventing and alleviating the nation’s physical-not its social-distress.