Statistics That Matter?
Criminal Justice
Blacks comprise roughly 13% of the U.S. population and 14% of the monthly drug users, but are 37% of the people arrested for drug-related offenses in the U.S.
In 2010, the U.S. Sentencing Commission reported that in the federal system, blacks receive 10% longer sentences than whites for the same crimes.
Source: https://www.dosomething.org/us/facts/11-facts-about-racial-discrimination
Reflecting on my last decade of medical training, I dove deep into understanding the marvels of the human body when it is healthy and diseased, and learning what treatments, whether it be surgical, medical, or lifestyle interventions, might help a patient achieve what we want everyone to achieve: optimal health. However, I have also witnessed and been exposed to the unimaginable complexities of the social structures that impede one’s ability to achieve actual health.
Academically, these are called the social or upstream determinants of health, which has also been referred to as the hidden curriculum in medical education. It’s not that we don’t receive any formal education on this, as there are definite curricular attempts to introduce it. Since my first year of medical school, I’ve listened to lectures informing me about the disparities between things like race and socioeconomic status among various diseases. Unfortunately, this is often where the conversation stops, and only rarely do we have a more meaningful discussion about issues such as why people are living in poverty in the first place and how that might impact their health.
Education System
Black children as young as 4 years old are given 50% of all out of school suspensions, yet they only comprise 18% of preschool enrollment.
In 2014, in Chicago, IL, the overall student population is about 25% white, 31% black, and 37% Hispanic, but 96% of black students attend majority non-white schools and 67% of white students attend majority white schools. Similar patterns emerge in other large cities across the country
Furthermore, after spending a few months rounding in the hospital, seeing patients in the emergency department, or rushing through a busy clinic, it quickly becomes clear that issues of health disparities along racial and socioeconomic lines are poorly understood and often neglected as a significant factor into a patient’s health.
All too often, I hear many in the health care workforce quickly jumping to conclusions about how patients’ lifestyle choices and genetics are the main determinants of an individual’s health, when we very well know that there is so much more involved than that simplistic mindset or view. It is incredibly frustrating.
Economy
Job applicants with white-sounding names are 50% more likely to get called in for an interview.
In 2015, the Department of Housing and Urban Development financially settled with the largest bank headquartered in Wisconsin over claims that it discriminated from 2008-2010 against black and Hispanic borrowers in Wisconsin, Illinois and Minnesota.
By no means do I mean to dampen the amazing efforts social workers, case managers, and others play in trying to bridge the gaps and offer solutions for issues such as housing and medical costs. However, these services do not have the infrastructure in place to tackle the underlying root causes of why these issues exist in the first place. This is not the fault of any individual, rather it is a fundamental flaw in a health care delivery system that is designed to be much more reactive rather than proactive.
In order to understand the complexities of how one gets to a certain health outcome, we need to understand and thoughtfully tackle these societal structures that are predictably setting the stage for the ultimate progression and formation of disease, hitting people of color harder and faster.
Health Care
A 2012 study found that about two-thirds of primary care doctors harbor biases toward their black patients, leading those doctors to spend less time with their black patients and involve them less in medical decisions.
A report from the Institute of Medicine found that blacks received less effective care than their white counterparts for nearly every disease studied.Source: http://thinkprogress.org/health/2015/02/23/3625706/doctors-racism-health-system/ and http://iom.nationalacademies.org/Reports/2002/Unequal-Treatment-Confronting-Racial-and-Ethnic-Disparities-in-Health-Care.aspx
Over the years, I started to see a whole new world of understanding unravel as I began to find solace in studying these complex issues outside of traditional curricula in medicine. I hope to begin to see more partnerships forging between medicine, public health, and the social sciences to tackle the difficult challenges we are faced with when trying to understand how a patient is where they are today, and more importantly, designing the solutions to the problems identified.
Rightfully or not, medical professionals, and arguable doctors more than others, have a societal status that gives our voices greater credibility. In my eyes, this means that we have an obligation to society and humanity to get much more involved than we already are. I hope to see more advocacy from all facets of the health care workforce to transform the national dialogue and to publicly advocate for progressive changes in law and policy.
Society
In 2012, 51% of Americans expressed anti-black sentiments in a poll; a 3% increase from 2008.
Sales of Apple’s Ipod were compared with black hands and white hands holding the Ipod in the advertisement. Black hands receive 13% fewer responses and 17% fewer offers, and buyers are 56% more likely to express concern about making a long-distance payment.Source: http://usnews.nbcnews.com/_news/2012/10/27/14740413-ap-poll-majority-harbor-prejudice-against-blacks?lite and http://news.stanford.edu/news/2010/july/hands-craigslist-study-071910.html
Right now, more physicians could lend a voice to movements like Black Lives Matter and Campaign Zero, which are trying to advocate for criminal justice reform that is disproportionately harming people of color.
I never want to paint a bleak picture without offering some semblance of hope. I look at initiatives going on in health care that are thoughtfully teaching and carrying out initiatives, some right here in our Department of Community and Family Medicine at Duke University, to tackle a variety of challenges that face our most vulnerable in society. I just wished there was more of a sense of urgency to change our system, and that more specialties in medicine will feel the moral imperative to do what is truly best for our patients.
Environmental
In the U.S., there are 3.8 million people who live in “fenceline” zones of 3,433 chemical facilities, which are closest to potential harm in the event of a catastrophe. The percentage of blacks and Hispanics in the “fenceline” zones is 75% and 60% greater, respectively, than for the U.S. as a whole.
Out of 149 metropolitan areas with known hazardous waste sites, 105 are host neighborhoods to predominantly majority poor black and Hispanic communities.Source: http://takingnote.blogs.nytimes.com/2014/05/02/facts-figures-environmental-racism/?_r=0 and https://baptistnews.com/opinion/commentaries/item/8756-environmental-racism-afflicts-us-minorities
We are quick to prescribe interventions and come up with a disposition for a patient, often algorithmic or protocol driven, but, we rarely incorporate or tackle or even try to empathize with patients to answer the difficult questions.
The United States is plagued by issues of injustice in the criminal justice system, racism, forces that keep people in poverty, segregation in the public education system, environmental injustice and limited economic opportunity for people of color. How do these issues trickle down to poor health outcomes? What are the statistics that really matter in health care, that are not taught in the formal curricula of our education? How can we meaningfully begin a dialogue around advocating for solutions to these societal ills?
“Of all the forms of inequality, injustice in health care is the most shocking and inhumane.” — Martin Luther King, Jr.
Farhad Modarai is a third-year resident with the Duke Family Medicine Residency Program. Email farhad.modarai@duke.edu with questions.
Editor’s note: Duke Family Medicine residents guest blog the second Friday of every month.