Story at a glance

  • People of color receive health care that is 40 percent worse than white patients, according to studies.
  • Environmental factors like air pollution make the disparity worse.
  • But the numbers can be turned around with a more wholistic approach.

There’s no doubt about it: The unequal distribution of health care in the United States is killing many of us.

The chasm of health disparities between minority groups and white people could be a mile wide. Doctors are less likely to refer a black patient for cardiac evaluation when presenting with chest pain than a white patient. Emergency medical services take black and Hispanic patients to different hospitals than white patients, even when they live in the same ZIP code. Overall, black patients receive worse care than white patients by a staggering 40 percent of quality measures.

This is far from a new set of problems. For hundreds of years, white doctors have pushed horrific false narratives about physiological differences between black and white people that served as a warped basis for justifying inhumane treatment of enslaved people. This 19th century “research” has seemingly not been supplanted by more accurate medical knowledge in some cases, and the gap between health outcomes for white people and minority groups has not closed. This raises the question: What is being done about it?

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The role of implicit bias

The first step is realizing race is a social construct not a biological one, notes Nathan Stinson Jr., the director of the division of scientific programs at National Institute on Minority Health and Health Disparities (NIMHD), which is part of the National Institutes of Health (NIH).

“Decreases in health disparities are not going to be found solely on a biological basis,” he says, noting that biology does matter but is only one of many factors causing minority health disparities.

One cause of these health disparities with deep roots is implicit bias. Stinson says NIMHD and other NIH agencies are investing in studying the impacts of implicit bias, but “sometimes the first hurdle is getting people to recognize that it does exist in itself.”

Within the past decade, research into psychological biases against minority patients has shown implicit bias is omnipresent in the medical system. A 2016 study shows white doctors who subscribe to unsupported notions about physiological differences between white and black people lead to an underestimation of the pain of the black patient and therefore provided inaccurate treatment recommendations for black patients.

Even data from archival information from the National Football League shows that injured black players are deemed OK to play in the next game when compared with injured white players, and the researchers say that may be because of this pain perception bias that has roots in the 19th century. These false narratives have likely played a large part in the distrust in the health care system for many minorities.

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Unequal air

Beyond ingrained psychological bias, external factors are undoubtedly a cause of differences in health outcomes. The United States is a place where the ZIP code you are born in can determine your destiny. The reason for this is primarily due to poverty, but poverty is also related to poor environmental health.

Anjum Hajatan assistant professor of epidemiology at the University of Washington, researches how environmental stressors disproportionately impact the health outcomes of minorities.

“Time and again,” Hajat says, “it's low income and racial minority groups that tend to bear the worst burden of air pollution.”

A study released earlier this year shows black and Hispanic people inhale air pollution more than white people but air pollution is disproportionately caused by white people. The study shows white people experience what researchers call a “pollution advantage,” while black and Hispanic people bear a “pollution burden.”

Last year, Hajat was part of a study that showed high levels of air pollution can even be tied to psychological health.

No quick fix

“We’ve been funding projects for decades, but we look at some of these charts and we still see some of these disparities still exist and some may have gotten worse,” Stinson says.

Hajat echoes the point: “It's just not going away. But yet, we've been talking about it and thinking about it and doing research about it for a really long time as well ... it’s just a difficult problem.”

One effective tool for reducing minority health disparities in the past five years has been expanding the availability of health care to those earning far below the poverty line. The Affordable Care Act (ACA) and Medicaid expansions have brought health care to minority groups that previously went unserved. These sorts of policy changes have tangible implications for health care outcomes, too. A recent study links the expansion of Medicaid to fewer cardiovascular deaths. The ACA is also responsible for a reduction in the racial disparities of cancer diagnosis and care.

“Any solutions to health disparities are going to really require addressing it from a multilevel point of view,” says Stinson, noting this is a shift in the way these problems have been tackled in the past.

He says his institute spent years in a new visioning process, thinking about how to tackle minority health disparities from a variety of different standpoints. The result of this visioning process was a series of reports released earlier this year he hopes will galvanize the research and policymaking community.

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The Environmental Protection Agency (EPA) is responsible for air pollution regulation, but in the current political climate, Hajat says, she feels the agency is rejecting scientific research that has helped guide decision-making in the past. This feeling is being borne out by policy changes: In the area of air pollution and emissions alone, the EPA has already rolled back or started to rollback 24 regulations. It is difficult to predict the impact these rollbacks may have on environmental stressors in minority communities in the future.

“The policy piece is one part, and that could be a national-level solution,” Hajat says, but she also notes that community and individual level solutions, like air pollution filters, have been shown to help. “So that's a little bit of a band-aid approach, but at least it helps alleviate some of the suffering that people are going through ... maybe that instead of six asthma attacks a year, you only get one, because you have clear air to breathe inside.”

With an issue so vast, one of the major keys to unlocking the inexorable issue of minority health disparities may lie in the communities impacted, Hajat says. She thinks the move toward community-based participatory research is an improvement.

“We don't need to, as academics, sit around and postulate and say, ‘Oh, this is your problem.’ What we really need to be doing is talking to communities that are affected by these problems and saying, ‘Hey, what do you think is the problem?’ ” she says.

Published on Nov 13, 2019