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Racial and Ethnic Disparities
in Health and Health Care
Kevin Fiscella, MD, MPH
University of Rochester School of Medicine & Dentistry
Departments of Family Medicine
Community & Preventive Medicine
What is race?
How we define race strongly affects how
we conceptualize the relationships
between race and health and health care.
What is race?
• “A group of people of common ancestry
distinguished by physical characteristics such
as hair type, eye or skin color, etc.”
-Collins English dictionary, 1998
• Geographic origin of ancestry –1997 OMB standards
• “Ideology of inequality devised to rationalize
European attitudes and treatment of the
conquered and enslaved peoples.”- American
Anthropological Association Statement, 1998
What is ethnicity?
• Shared cultural, national, religious or
linguistic heritage
• Hispanic or non-Hispanic origin –1997 OMB
standards
Racial and ethnic disparities in
mortality
• African Americans have the highest ageadjusted mortality rate of any group, followed
by whites, American Indians/Alaska Natives,
Hispanics, and Asians, Native Hawaiians or
other Pacific Islanders.
• Deaths for American Indians/Alaska Natives
and Hispanics tend to be misclassified on death
certificates, so vital statistics underestimate
mortality rates for these groups.
Disparities in
cause-specific mortality
• Blacks have higher death rates than whites
from all the leading causes of death except
suicide and chronic lung disease. HIV death
rates are 10 times higher and homicide rates
are more than 7 times higher among blacks
than whites.
• Hispanics have 3 times higher rates of death
from HIV and homicide than whites and higher
rates from liver disease and diabetes, but lower
rates than whites for all other major causes
including heart disease and cancer.
Disparities in
cause-specific mortality
• Asians have lower death rates than whites in all
categories except homicide.
• American Indians/Alaska Natives have higher
death rates than whites from liver disease,
diabetes, HIV, accidents and homicide, but
lower death rates from heart disease and
cancer.
Life expectancy for African
Americans is nearly six years
less than whites
• Disparities in socioeconomic status
explain much of this gap.
• Disparities in cardiovascular mortality
explain nearly one third of the gap.
• Hypertension represents the single
largest contributor to this gap.
Black-white disparities in
health begin in utero
• Black infant mortality rate is two and half
times higher than that of whites.
• Most of this gap is due to racial differences in
rates of very low birth weight.
• The primary causes of very low birth weight
are intrauterine infection and hypertensive
disorders that result in preterm birth.
• Sudden infant death is the major cause of
racial disparities in post neonatal mortality.
Black-white disparities in
maternal mortality
• African American women die during
pregnancy and child birth at five times
the rate of whites.
• The primary causes of this gap is
disparities are vascular and infection
related complications and homicide.
Fundamental causes
of racial disparities in health
and well being
• Poverty
• Segregation
• Racism
Poverty
• More than one out of three black children
under the age of 6 lived in poverty in 2000
(twice the rate of whites).
• Blacks earn on average 62% of that of whites.
• Among equivalent income or educational levels,
blacks have far less wealth than whites.
Segregation
• African Americans experience greater and more
persistent residential segregation than any other
group “hypersegregation.”
– Massey, 1989
• Residential segregation and confinement to
impoverished central cities has a devastating
impact on the economic, educational,
psychological, and physical well-being of African
Americans. –Williams, 2002
• Segregation undermines social cohesion, reinforces
individual, institutional, and internatalized
racism.
Racism
Institutional and individual practices that
create and reinforce oppressive systems
of race relations whereby people and
institutions engaging in discrimination
adversely restrict by judgment and
action, the lives of whom they
discriminate against. -Krieger 2003
Categories of racism
• Individual racism - Ideology of inherent,
biological superiority of one race over another that
is used to justify discrimination.
• Institutional racism - Policies and practices that
systematically reinforce the power and privilege of
one racial group over another.
• Internalized racism - Introjection of pejorative
messages by stigmatized racial group regarding
their capabilities and behavior.
These categories reinforce
each other
• Unconscious racist assumptions (individual
racism) result in national, state, and local
policies (institutional racism) that reinforce
racial stratification. Examples include
educational, correctional, and economic
policies.
• Persistent poverty, despair, stigma, and loss of
community role models reinforce internalized
racism.
Context matters
• Poverty, segregation, and racism do not operate
in isolation from each other. It is the confluence
of these factors that undermines the well being
of African Americans.
• Current conditions cannot be understood in the
absence of their historical context.
• The impact of poverty on a black child growing
up in the inner-city is qualitatively different
than that of a first generation Mexican or Asian
child.
Race and genetics
• Race is a social construct without biological basis; there
is far greater genetic diversity within racial categories
than between them.
• Because race is associated with geographic ancestral
origin and because differences in geographic origin are
associated with genetic allele frequency, allele
frequency occasionally differs by race.
• These differences do not negate the social construction
of race.
• Only a few conditions result from the effects of single
alleles. Genetic differences by race are unlikely to
explain most disparities in chronic diseases.
Causal pathways across the life course
• The pathways through which racism,
segregation, and poverty affect black well-being
are complex.
• Effects early in life may have lasting effects, e.g.
fetal nutrition, lead toxicity, cognitive
stimulation.
• Risk factors among disadvantaged groups tend
to cluster and generate downward trajectories.
• Risk factors tend to have cumulative effects
over time.
Specific mediators of disparities
• Intrauterine environment - Fetal origins of disease
hypothesis suggests that low birth weight infants are at
higher risk for diabetes, hypertension, obesity, renal
disease, and heart disease.
• Physical environment - Exposure to lead and other toxins,
violence, availability of food, alcohol, and illicit drugs.
allergens, passive smoke, crowding, infections, and diet.
• Family environment - Presence of two adult age parents,
early cognitive stimulation, absence of abuse, and role
models.
• Social environment - Impact of peers, expectations of
future, risk of violence, opportunities for self expression,
social network and support, and opportunities for marriage.
Specific mediators of disparities
• Psychological environment - Psychosocial stress from
discrimination, autonomy/control, stigma, and internalized
racism.
• Educational environment - Levels of expectations,
concentration of students at risk, and resources.
• Work environment - Job opportunities, control of work,
opportunities for advancement, risk of physical injury.
• Cultural environment - Norms of health related behavior
e.g. breast feeding, infant sleeping position, douching,
attitudes towards immunizations and health care.
• Health care environment – Large disparities documented.
Exposure
to toxins,
allergens,
&
infections
segregation
Racism
Intrauterine
effects
Childhood
poverty
Cognitive
stimulation
Marriage
Family function
Community
decline
Peer
effects
cognitive and
emotional
development
stress
Educational
achievement
Access to
health care
behavior
Access to
social
networks
employment
Health
•Adult
poverty
Racial and ethnic disparities in
health care
• Disparities differ by type of health care and
by racial and ethnic group.
• Disparities are best documented and most
severe for African Americans.
Disparities in types of health
care
• Preventive services
• Medical treatment
• Surgical procedures
• Interpersonal care
Disparities in preventive care
•
•
•
•
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•
•
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Prenatal care (number of visits and quality)
Child immunizations
Well child visits
Adolescent immunizations
Pap smear screening
Breast cancer screening
Colon cancer screening
Influenza & Pneumococcal immunization
Smoking cessation advice
Disparities in medical
treatment
•
•
•
•
Acute & chronic pain
Asthma
Chemotherapy
Congestive heart
failure
• Coronary artery
disease
• Depression
•
•
•
•
•
•
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Diabetes
Dialysis
HIV
Hypertension
Myocardial Infarction
Pneumonia
Stroke
Disparities in surgical or
invasive procedures
•
•
•
•
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Organ transplantation
Curative cancer surgery
Cardiovascular procedures/surgery
Cerebrovascular procedures/surgery
Hip and knee replacement surgery
Disparities in satisfaction and
interpersonal care
•
•
•
•
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Health care satisfaction
Physician satisfaction
Physician trust
Involvement in care
Perceived discrimination
Causes of disparities in
health care
•Societal factors - Differences in presence and
type of health insurance and systems of care.
•Patient factors - Literacy, knowledge, beliefs,
attitudes, language and norms.
•Physician factors - Unconscious stereotyping,
cultural insensitivity, and poor communication
skills
Societal factors
• More than 50% of Hispanics and 40% of
African Americans lacked health insurance at
some point during 2001.
• Minorities more likely to be seen by residents.
• Presence and type of health insurance
contribute to, but do not fully explain,
disparities in health care.
Patient factors
• Patients beliefs, attitudes, knowledge,
preferences and literacy contribute to
disparities.
• Patient factors do not fully explain
disparities.
• Patient factors are strongly influenced by
system and provider factors.
Physician factors
• Overt prejudice - “I won’t recommend bypass surgery
because this patient is black.”
• Stereotyping - “I won’t recommend kidney transplantation
because most blacks do not adhere to treatment.”
• Clinical uncertainty - “I won’t recommend angiography
because the patient’s symptoms are too dramatic (or not
dramatic enough) to warrant the risk of this procedure.”
• Poor communication - Absence of patient-centered care
and patient-physician partnership.
Patient-centered care
• Represents a core dimension of health quality as
defined by the IOM.
• Involves a set of core communication skills
necessary to insure patient involvement in their
care.
• Skills include obtaining knowledge of the patient
as a person, eliciting the patient’s perspective on
their condition.
• Explaining treatment options in understandable
terms.
• Eliciting the patients preferences for treatment
• Confirming the patient’s understanding of the
specifics of the treatment plan.
Minorities receive less patientcentered care
• Physicians adopt a more directive style,
provide less information, and engage in less
partnership with minority patients.
• The result is lower rates of adherence and
lower quality care.
Equity is a core dimension
of quality
• Equity recognized by the Institute of
Medicine in 2001.
• Quality assurance must include measures of
disparity.
• Quality Improvement represents an
important means for addressing disparities
in care.
• Recent data suggest that quality
improvement reduces disparities.
Implications for addressing
disparities in health & health
care
• The Healthy People 2010 goal of eliminating disparities
in health requires addressing fundamental causes of
disparities.
• Academic-community partnerships represent an important
means for addressing fundamental and proximate causes of
disparities at the local level.
• The elimination of disparities in health care will require
initiatives leverage existing quality improvements efforts
that address physician and patient factors.
• Quality improvements offer the greatest potential for
change when they are strongly tied to the community.
• Disparities in access including insurance must be
addressed