There are two health care systems in the United States: one for white America and one for Black America. To address this reality, we must devise comprehensive, long-term solutions, but first, let’s explore what we mean when we say that there are two different systems.
The American Bar Association explains:
“In 2005, the Institute of Medicine — a not-for-profit, non-governmental organization that now calls itself the National Academy of Medicine (NAM) — released a report documenting that the poverty in which black people disproportionately live cannot account for the fact that black people are sicker and have shorter life spans than their white complements. NAM found that ‘racial and ethnic minorities receive lower-quality health care than white people — even when insurance status, income, age, and severity of conditions are comparable.’ By ‘lower-quality health care,’ NAM meant the concrete, inferior care that physicians give their black patients. NAM reported that minority persons are less likely than white persons to be given appropriate cardiac care, to receive kidney dialysis or transplants, and to receive the best treatments for stroke, cancer, or AIDS. It concluded by describing an ‘uncomfortable reality’: ‘some people in the United States were more likely to die from cancer, heart disease, and diabetes simply because of their race or ethnicity, not just because they lack access to health care.’
“Scores of studies buttress NAM’s findings by documenting that providers are less likely to deliver effective treatments to people of color when compared to their white counterparts — even after controlling for characteristics like class, health behaviors, comorbidities, and access to health insurance and health care services. For example, one study of 400 hospitals in the United States showed that black patients with heart disease received older, cheaper, and more conservative treatments than their white counterparts. Black patients were less likely to receive coronary bypass operations and angiography. After surgery, they are discharged earlier from the hospital than white patients — at a stage when discharge is inappropriate. The same goes for other illnesses. Black women are less likely than white women to receive radiation therapy in conjunction with a mastectomy. In fact, they are less likely to receive mastectomies. Perhaps more disturbing is that black patients are more likely to receive less desirable treatments. The rates at which black patients have their limbs amputated is higher than those for white patients. Additionally, black patients suffering from bipolar disorder are more likely to be treated with antipsychotics despite evidence that these medications have long-term negative effects and are not effective.”
This disparity is pervasive and is perhaps best illustrated through maternal mortality rates. According to the Centers for Disease Control and Prevention, the pregnancy-related mortality rate for non-Hispanic Black women is 40.8 per 100,000 births. For white women? 12.7 per 100,000 — more than three times lower. When over the age of 30, Black women are four to five times more likely to die than white women, and when they have a college degree, Black women are 5.2 times more likely to die than their white counterparts. The latter figures demonstrate the importance of being able to advocate for yourself in health care environments, and they further demonstrate that even — and especially — when Black women advocate for themselves, they are less likely to receive adequate care compared to white Americans.
Consider the case of Serena Williams.
One day following the emergency C-section birth of her daughter, Williams found herself unable to breathe. Walking out of her hospital room, Williams approached a nurse and told her that she feared that she had a blood clot and that she needed a CT scan and blood thinner. Williams, you see, had experience with this. It was 2011 when she suffered her first hematoma and pulmonary embolism, and she was well-versed on the symptoms.
In response to her valid and experience-based concerns, the nurse dismissed Williams and explained to her that her pain medication was simply making her confused.
But Williams wasn’t confused. And after continued and insistent prodding, a CT scan was eventually performed, turning up several blood clots in her lungs.
A subsequent surgery would reveal a hemorrhage at her C-section site.
What if Williams had simply acquiesced? Accepted that her nurse knew better? Allowed her medical team to guide her care? She might not be here today.
And if Serena Williams — the most powerful Black woman in all of sports, a woman with intricate knowledge of the medical condition claimed — was not to be taken seriously, imagine the response to your average civilian.
Unfortunately, Williams’ case is far from unique, and for too many Black women in the United States, pregnancy serves as a veritable death sentence. Despite living in America, these women do not receive America-quality care. In fact, according to the World Health Organization, their odds of surviving childbirth are more comparable to those of women living in Malaysia, Mexico, and Uzbekistan.
As Neel Shah, an obstetrician-gynecologist and director of the Delivery Decisions Initiative at Ariadne Labs, put it, “The common thread is that when black women expressed concern about their symptoms, clinicians were more delayed and seemed to believe them less. It’s forced me to think more deeply about my own approach. There is a very fine line between clinical intuition and unconscious bias.”
First, we must address the structural inequities that exist to make Black Americans sicker, on average, than their white counterparts. Poverty levels, housing, health insurance coverage, number and kind of hospitals in the region: all of these factors impact a person’s access to quality care, and Black Americans are disproportionately affected across all areas.
According to the National Institute of Health, Black Americans have lower levels of health insurance coverage than white Americans, limiting access to routine and preventative care. Geographic variation in healthcare means that facilities in states with a large proportion of Black residents tend to provide less appropriate treatment options than do facilities in states with a different demographic makeup.
Thus, we will need to address disparities in personal and social resources, socioeconomic status, and in the macrosocial environment if we are to ameliorate some of the root causes of the imbalance.
But we must also accept and address the fact that, even in the absence of these disparities, disparate treatment continues to exist. Even when we remove barriers to access, problems persist. So it is imperative upon our hospitals and healthcare systems to implement standardized protocols in quality improvement initiatives and to identify and address implicit bias in an effort to improve health outcomes.
Because, ultimately, it is going to take a collaborative approach to overhaul our systems and correct the issue.
Functionally, from a policy perspective, this means creating a national task force on health equity, collecting and studying relevant data, expanding access to Medicare and Medicaid, investing in virtual care and broadband infrastructure, establishing health equity zones, funding urban and rural healthcare systems, addressing hospital and provider shortages, and providing training on implicit bias.
Yes, this will involve a significant financial investment, but aside from it being morally necessary, it is also fiscally prudent. After all, studies have found that by reducing racial health inequities, we could have reduced our economic burden by $230 billion in medical expenditures and $1 trillion in indirect costs from 2003-06.
As the study’s authors write, “We should address health disparities because such inequities are inconsistent with the values of our society and addressing them is the right thing to do, but this analysis shows that social justice can also be cost effective.”
If you would like to learn more about health inequities, consider picking up a copy of “Just Medicine: A Cure for Racial Inequality in American Health Care” by Dayna Bowen Matthew, “The Health Gap” by Michael Marmot, “The Death Gap: How Inequality Kills” by David A. Ansell MD, or “The Broken Ladder: How Inequality Affects the Way We Think, Live, and Die” by Keith Payne.
A list of black-owned independent bookstores can be found here.
And if you would like to contribute to the cause, consider getting involved with or making a donation to Black Mamas Matter Alliance, Sisters Network, Black Women’s Health Imperative, Mamatoto Village, The Loveland Foundation, Black Mental Health Alliance, The Center for African American Health, African American Planning Commission, African American Health Coalition, American Sickle Cell Anemia Association, Black AIDS Institute, or the Center for Black Women’s Wellness.