I. INEQUITY IN HEALTH STATUS: BRIEF REVIEW
The need to focus specific attention on the discrimination inherent in the institutions and structures of health care is overwhelming. Racial minorities are sicker than white Americans; they are dying at a significantly higher rate. These are undisputed facts. Many examples of inequities in health status between racial/ethnic groups exist: infant mortality rates are 2 times higher for blacks, and 1 times higher for American Indians, than for whites; the death rate for heart disease for blacks is higher than for whites; 50 percent of all AIDS cases are among minorities who account for only 25 percent of the U.S. population; the prevalence of diabetes is 70 percent higher among blacks and twice as high among Hispanics as among whites; Asian Americans and Pacific Islanders have the highest rate of tuberculosis of any racial/ethnic group; cervical cancer is nearly five times more likely among Vietnamese American women than white women; women are less likely than men to receive lifesaving drugs for heart attacks; more women than men require bypass surgery or suffer a heart attack after an angioplasty.
Yet, despite these significant health status inequities, we have denied many Americans equal access to quality health care based on race, ethnicity, and gender. Factors that contribute to this inequity in health care include the following: cultural incompetence of health care providers, socioeconomic inequities, disparate impact of facially neutral practices and policies, misunderstanding of civil rights laws, and discrimination contribute to inequities in health status, access to health care services, participation in health research, and receipt of health care financing.
Drs. Michael Byrd and Linda Clayton clearly laid out the long history of racism and medicine in their seminal work: “An American Dilemma: A Medical History of African Americans and the Problem of Race, Beginnings to 1900‘ and “An American Dilemma: A Medical History of African Americans and the Problem of Race, 1900 to 2000.‘ In their work, Drs. Byrd and Clayton show that the problem of black health status and black health care access is a part of a long continuum of racism and racial discrimination dating back almost 400 years. In fact, since colonial times, the racial dilemma that affected America also distorted medical relationships and institutions. Throughout our history, we have actively assigned racial minorities to the underfunded, overcrowded, inferior, public health care sector.
Historically, medical doctors and medical leadership helped to establish and maintain a racially discriminatory health care system. They helped to establish the slaveocracy, create the racial inferiority myths, build a segregated health subsystem, and maintain racial bias in the diagnosis and treatment of patients. Only after 350 years of active discrimination and neglect, were efforts made to admit minorities into the “mainstream” health system. However, these efforts were flawed and since 1975 minority health status has steadily eroded. Consequently, minorities continue to experience racial discrimination in access to health care and quality of health care received.
Yet, current issues in health inequities are not isolated to problems in the health system. They are the cumulative result of both past and current racism throughout US culture. For instance, because of institutional racism, minorities have less education and fewer educational opportunities. Minorities are disproportionately homeless and have poorer housing options. Due to discrimination and limited educational opportunities, minorities disproportionately work in low pay, high health risk occupations (e.g., migrant farm workers, fast food workers, garment industry workers). Historic and present racism in land and planning policy also plays a critical role in minority health status. Minorities are much more likely to have toxic materials (and other unhealthy uses) sited in their communities than whites despite income. For example, over-concentration of alcohol and tobacco outlets and the legal and illegal dumping of pollutants pose serious health risks to minorities. Exposure to these risks is not a matter of individual control or even individual choice. It is a direct result of discriminatory policies designed to protect white privilege at the expense of minority health.
