Better Health Care Newsletter – November 2023 | Patrick Malone & Associates P.C. | DC Injury Lawyers

We can all agree that health and wellness should be equal opportunity goals for all Americans, and your skin color shouldn’t matter. But it does.

The health numbers for Blacks, Latinos and Asian Americans are so different from white Americans, and have persisted for so long, that we are finally doing something about it.

The reforms should help the health care of everyone, as we learn the ways to plug the racial and ethnic health gaps.

Meantime the patterns are striking:

Black Americans, as the Associated Press found in a year-long investigation, “have higher rates of infant and maternal mortality, higher incidence of asthma during childhood, more difficulty treating mental illness as teens, and higher rates of high blood pressure, Alzheimer’s disease, and other illness as adults.”

Diabetes and obesity plague Latinos in this country, adding to their struggles with poverty and access to the U.S. medical system.

As federal medical scientists have reported: “Asian Americans have the highest incidence and mortality rates of liver and stomach cancers — the most preventable cancer — largely due to high prevalence of related infections such as hepatitis B. In addition, Asian Americans have the lowest cancer screening rates and are typically diagnosed at a later stage compared to other racial and ethnic groups.”

It took the pandemic to bring long simmering racial disparity issues to a boil.

Confronted with disproportionate Covid-19 deaths and debilitations of minority patients in a pandemic that killed more than 1 million Americans, doctors, hospitals, medical schools, and medical scientists have undertaken a painful but necessary review to treat patients more equally and fairly.

Big changes are still needed. But already some surprises have emerged, and important lessons have been learned, providing patients and medical providers with valuable takeaways for improved medical care for us all.

The issue of race can be so fraught that some advocates say the nation best presses toward a more ideal world by ignoring it altogether. We’re more equal this way, they contend.

Rigorous research provides evidence to the contrary, finding that there are measurable differences among us and our health outcomes based on race. People are individual, different, and their race can be a major factor in population health and medical care. Startling proof of this is building in studies scrutinizing a fundamental, common-sense concern, especially for black patients: the importance of black doctors.

The presence of just one black doctor within a U.S. county led to increased longevity and lower mortality among all blacks living there, according to Stat, a science and medical news site, reporting on a study published in the medical journal JAMA Network Open. As Stat said of the examination of health and other data from 1,600 U.S. counties:

“The study … is the first to link a higher prevalence of black doctors to longer life expectancy and lower mortality in black populations. Other studies have shown that when black patients are treated by black doctors, they are more satisfied with their health care, more likely to have received the preventive care they needed in the past year, and are more likely to agree to recommended preventive care such as blood tests and flu shots. But none of that research has shown an impact on black life expectancy.

“The new study found that black residents in counties with more black physicians — whether or not they actually see those doctors — had lower mortality from all causes and showed that these counties had lower disparities in mortality rates between black and white residents. The finding of longer life expectancy persisted even in counties with a single black physician. ‘That a single black physician in a county can have an impact on an entire population’s mortality, it’s stunningly overwhelming,’ said Monica Peek, a primary care physician and health equity researcher at UChicago Medicine who wrote an editorial accompanying the new study. ‘It validates what people in health equity have been saying about all the ways black physicians are important ….’”

For black and brown patients, though, the potential benefits of having doctors that look like them runs into blunt reality: the dearth of black (and Latino) MDs, whether in vital primary care practices or as medical specialists. As the AP reported, “Black Americans represent 13% of the U.S. population, yet just 6% of U.S. physicians are black.” (Latinos make up 20% of the U.S. population but just 7% of U.S. doctors.)

Further, the U.S. Supreme Court — siding with affirmative action foes and asserting that “race blind” admissions are the fair way for colleges and universities to go — has spiked concerns that the “path into medicine may become much harder for students of color.” Medical educators and other experts already are racing to determine how they can ensure that the country has a robust number of black and Latino doctors.

They are, as a group, poorer than most, often lagging in education, and less likely to have access to medical care. They suffer outsized harms from diabetes, obesity, high blood pressure, and heart disease. Their diet, high in carbohydrates, calories, and excess sugar, raises concern among many health experts.

Yet on average, Latinos or Hispanics live a few years longer than their white counterparts. What gives?

This “Hispanic Paradox,” so named in 1986 by University of Texas researchers Kyriakos Markides and Jeannine Coreil, has perplexed medical researchers for decades. Stat, the science and medical news site, says contemporary studies are adding nuance to the issue:

“They’re finding that for Hispanics, living longer does not necessarily mean living healthier, and that lumping together people from places as varied as Brazil, Mexico, and Puerto Rico conceals important health risks for these individual populations, which may as a result go unnoticed by many American physicians. They’re also finding that healthy Hispanics who immigrate to the U.S. tend to get sicker the longer they stay — raising deeper questions about why our wealthy nation, which spends more than $4 trillion on health care, is far sicker than it should be. ‘Part of the story about the Hispanic Paradox,’ said Kyriakos S. Markides, a professor of aging at the University of Texas Medical Branch in Galveston, ‘is that the non-Hispanic white population is not doing as well as it should.’”

In the past, researchers have scrambled to explain Latino longevity, arguing unconvincingly that this occurred because the healthiest Hispanics returned to their homelands (nope), or that legumes (beans) in their diet offered health advantages (nope), or that the overall youthfulness of this population mattered (nope).

Researchers lately have tried to better understand Latino longevity, partly by diving deeper into the group and seeing its complexity — that is, that the Spanish-speaking peoples in this country come from an array of other nations and have distinct cultures [see below].

They share commonalities that studies suggest could play important roles in keeping humans healthier: Many Hispanics, researchers say, are spiritual and give certain powers to women and the individual, even in male-dominated, top-down societies. Latinos and those from Asian nations also are rooted in collective cultures in which communities support members in thick and thin, with extended families supporting those who are sick, debilitated, and old, Stat reported.

Americans of Vietnamese ancestry report in surveys that their health is fair or poor more than twice as often as non-Hispanic whites and Asian Americans overall. Those of Japanese ancestry, researchers at UCLA and Brown University have found, have a higher proportion of people who are obese or overweight than non-Hispanic whites and Asians overall. Japanese and Koreans report higher diabetes rates than non-Hispanic whites and Asians overall. Americans of Filipino descent appear to be in the worst health of all Asian subgroups. They have a greater prevalence of high blood pressure, asthma, heart disease, and delayed medication usage compared to Asians overall. They — along with Native Hawaiian and Pacific Islander people — suffered disproportionate deaths and debilitation during the coronavirus pandemic.

Until fairly recently, doctors, hospitals, policy makers, politicians, and other key players in the U.S. medical world might not have known vital health information like this.

That’s partly because a concerted campaign by U.S. activists of Asian descent successfully convinced many in this country of the existence and importance of a group called Asian Americans. These people are part of a rising, potentially politically powerful, accomplished, and increasingly affluent group living and working from coast to coast.

The descriptive term made sense, advocates say, dating to the 1970s and the efforts to win needed attention and clout for small, disparate groups of people tracing their roots to dozens of Asian nations. The description provided a crucial sense of identity, emphasizing “American-ness” and providing in unity a clout that had eluded people with a long history of harsh, unacceptable discrimination. This included exclusionary immigration policies, the unconstitutional incarceration of tens of thousands of citizens during wartime, and killings, beatings, and economic privation.

But over time, this country has made some progress. So, is being “Asian American” still a coherent idea when it encompasses new immigrant groups like the Burmese (annual median income $36,000) and Indians ($100,000+)? Do battles for more equitable treatment by Ivy League universities by Asian Americans with multiple generations in this country (such as those of Chinese and Japanese descent) resonate with impoverished newcomers from Cambodia, Nepal, and Bhutan?

Recent outbreaks of thousands of anti-Asian hate incidents argue — loudly — that Asian Americans (or AAs) need to retain the broad description of themselves to advance their cause.

The AA identification, as with terms like Latino and Hispanic (describing people rooted in other huge geographical areas) retains its value. Advocates say that establishment medicine also must work harder for “disaggregated data,” information on smaller subgroups that provides invaluable insight on their medical needs and treatment.

This information can be tougher and more time-consuming to develop and analyze — and for private and government funders to want to support.

But as Ninez A. Ponce, PhD, MPP, and director of the UCLA Center for Health Policy Research, has argued about sound medical policy making, based on hard data and factual evidence:

“We know that without data equity, we will not achieve health equity. But we also recognize that health inequity is rooted in systemic injustice, and we will work together to dismantle these barriers and achieve health justice. Health equity is not a destination, but an enduring process. “

As doctors, hospitals, and medical scientists delve into the national disgrace of Black mothers suffering disproportionate death and disease rates, a common theme keeps sounding. Why do so many Black women, no matter their economic or social standing, suffer so much during pregnancy and while raising their babies?

Their doctors fail to listen to them and take their medical concerns seriously. That’s a blunt truth the research is exposing.

Physician “gaslighting” is an unacceptable horror for women patients, in general, but it is lethal and debilitating for black women during pregnancy and after delivering, one of the most challenging parts of their lives, according to news media reports. Here is what the New York Times reported:

“Research suggests that diagnostic errors occur in up to 1 out of every 7 encounters between a doctor and patient, and that most of these mistakes are driven by the physician’s lack of knowledge. Women are more likely to be misdiagnosed than men in a variety of situations. Patients who have felt that their symptoms were inappropriately dismissed as minor or primarily psychological by doctors are using the term ‘medical gaslighting’ to describe their experiences and sharing their stories on sites like Instagram. The term derives from a play called Gaslight about a husband’s attempt to drive his wife insane. And many patients, particularly women and people of color, describe the search for accurate diagnosis and treatment as maddening. ‘We know that women, and especially women of color, are often diagnosed and treated differently by doctors than men are, even when they have the same health conditions,’ said Karen Lutfey Spencer, a researcher who studies medical decision-making at the University of Colorado, Denver.”

This newsletter has devoted an issue to this topic. We reported on data on U.S. care for the pregnant and their newborns that is nothing less than a national embarrassment:

Our spiking U.S. maternal mortality and morbidity rates put this country in the same neighborhood as Afghanistan, Lesotho, and Swaziland. Black women are more than three times as likely as white women to die from pregnancy-related causes, while American Indian/Alaska Native are more than twice as likely. These disparities persist regardless of income, education, geography, and other socioeconomic factors.

The crisis harms infants, too, the New York Times reported:

“The number of American babies who died before their first birthdays rose last year, significantly increasing the nation’s infant mortality rate for the first time in two decades, according to provisional figures released … by the National Center for Health Statistics. The spike is a somber manifestation of the state of maternal and child health in the United States. Infant and maternal mortality, inextricably linked, are widely considered to be markers of a society’s overall health, and America’s rates are higher than those in other industrialized countries. The rates are particularly poor among black and Native American mothers, who are roughly three times as likely to die during and after pregnancy, compared with white and Hispanic mothers. Their infants face up to double the risk of dying, compared with white and Hispanic babies.”

This year, ProPublica, a Pulitzer Prize-winning investigative site, dug into problems black patients experience with stillbirths, reporting:

“Black women overall are more than twice as likely as white women to have a stillbirth, according to 2020 CDC data, the most recent available. In some states, including South Carolina, Kansas, and Tennessee, they are around three times as likely to deliver a stillborn baby. In Arkansas and Mississippi, the stillbirth rate for black women in 2020 topped 15 per 1,000 live births and fetal deaths; it was more than 11 in New Jersey and New York. The national stillbirth rate for black women was 10.3 and for white women 4.7. But drawing focus to black stillbirths is a challenge in a country where stillbirths, in general, have been understudied, underfunded, and received little public attention. In addition, the community of stillbirth researchers and advocates remains relatively small and overwhelmingly white.”

The New York Times suggested in its report on women and gaslighting that patients should consider bringing along a friend or companion to join them in doctors’ offices for appointments, taking notes and helping in other ways. And doctors can take steps to remedy some of the issues the newspaper reported, quoting the University of Colorado’s Dr. Spencer.

It’s hard to know how to begin to address these systemic problems, experts said, but scientists argue that at the very least, there needs to be more research on women’s health conditions. Doctors should also be given more time with their patients, and see fewer patients overall, Dr. Spencer suggested.

As the Times reported: “Research has shown that when people are juggling many cognitive tasks, they are more likely to make biased decisions. One study found, for instance, that male doctors were less likely to prescribe pain medications to black patients with lower back pain when the doctors were under stress. Physicians are often working under difficult conditions that ‘make it easy to make mistakes and oversights,’ Spencer said. ‘It’s like a gauntlet of problematic systems and processes that invite bias.’ Researchers have also called for more training in medical school about unconscious bias and racism in health care. In 2019, California passed a law requiring hospitals to implement implicit bias programs for all health care providers who provide perinatal care.”

Now, as the Washington Post reported, this country confronts a “crisis of premature death,” with chronic illnesses debilitating far too many people, notably in the prime years of their lives. While the coronavirus, the opioid crisis, suicide, and illnesses like HIV-AIDS dominate public attention as prime health challenges, heart disease, cancer, diabetes, and liver disease keep taking a far deadlier toll.

Chronic illnesses, combined with obesity and smoking, bad political policymaking, and a deeply flawed medical system — other big factors that keep too many people sick —have riven the American people. We are divided more than ever, not only by politics and wealth but also by race, geography, and, most fundamentally, health and longevity, the Washington Post found in its year-long investigation of U.S. life expectancy data.

The substantial fall in life expectancy has made Americans, even the wealthy, laggards among their western industrial peers. The U.S. crisis starts far too early, with surprising illnesses afflicting kids. It has hit minorities hardest. As the Kaiser Family Foundation has reported:

“[P]rovisional data for 2021 show that life expectancy was lowest for [American Indian and Alaska Native people] at 65.2 years, followed by black people, whose expectancy was 70.8 years, compared with 76.4 years for white people and 77.7 years for Hispanic people. It was highest for Asian people at 83.5 years. Data were not reported for Native Hawaiian and Other Pacific Islander people. These declines were largely due to Covid-19 deaths and reflect the disproportionate burden of excess deaths, including premature excess deaths (before age 75), among people of color during the pandemic. “

The most recently available life expectancy data illustrates the shocking reverse in the health status of too many populations of color, with the native peoples’ declines taking them to lows not seen in the broader country since 1944, the news site Axios reported. An online post by Harvard Health publishing noted this:

“With rare exceptions, life expectancy has been on the rise in the U.S.: It was 47 years in 1900, 68 years in 1950, and by 2019 it had risen to nearly 79 years. But it fell to 77 in 2020 and dropped further, to just over 76, in 2021. That’s the largest decrease over a two-year span since the 1920s.”

Research published this fall seeks to quantify the “staggering” harm to black Americans due to racial inequities and early death and disability, as NBC News reported:

“[A] new study, published … in [the medical journal] JAMA, casts the nation’s racial inequities in stark relief, finding that the higher mortality rate among black Americans resulted in 1.63 million excess deaths relative to white Americans over more than two decades. Because so many black people die young — with many years of life ahead of them — their higher mortality rate from 1999 to 2020 resulted in a cumulative loss of more than 80 million years of life compared with the white population, the study showed.”

The Washington Post reported this of the nation’s plummeting life expectancy:

“The geographical footprint of early death is vast: In a quarter of the nation’s counties, mostly in the South and Midwest, working-aged people are dying at a higher rate than 40 years ago, The Post found. The trail of death is so prevalent that a person could go from Virginia to Louisiana, and then up to Kansas, by traveling entirely within counties where death rates are higher than they were when Jimmy Carter was president.”

Looking at the newspaper’s illustrative map, the areas with the biggest life expectancy declines are clustered in regions where minorities, especially rural communities of color, live. It is worth noting, though, that minorities live longer and healthier in big cities now, not in rural areas, as once occurred.

Fixing the overall problem of plunging life expectancy, as well as addressing inequities affecting minorities, won’t be easy or simple, experts agree. To do so would require patients, doctors, hospitals, insurers, employers, politicians, and others to tackle complex issues like:

§ covering the uninsured;
§ moving away from fee-for-procedure medicine;
§ slashing consumption of overprocessed foods, salt, and sugar;
§ invigorating campaigns to curb smoking and vaping;
§ significantly improving mental health care.

As the Washington Post also reported:

“[E]xperts studying the mortality crisis say any plan to restore American vigor will have to look not merely at the specific things that kill people, but at the causes of the causes of illness and death, including social factors. Poor life expectancy, in this view, is the predictable result of the society we have created and tolerated: one riddled with lethal elements, such as inadequate insurance, minimal preventive care, bad diets, and a weak economic safety net.”

Big Pharma, major medical device manufacturers, and makers of various medical tests are legendary for how they have worked to maximize profits. Their actions and history tell how they covet one color — green, the color of money. So, patients who are black, brown, and yellow should not suffer inequities with prescription medications and medical devices, right? Wrong.

As medical researchers and doctors long have known, disparities are rife, for example, in how drugs are prescribed to patients of color and whether those who need medications get and use them. A 2020 published study by a University of Rhode Island pharmacy college professor summed up some of the drug issues, reporting:

“Racial disparities have been documented in the use of essential evidence-based drug therapies, including antidepressants, anticoagulants, diabetes medications, drugs for dementia, and statins, to name a few. Racial or ethnic disparities in medication use have been associated with the failure to achieve therapeutic goals, increased rates of hospitalization, and decreased survival.^”

The Commonwealth Fund — an independent, nonpartisan, nonprofit group that zeroes in on critical issues in health care — recently hosted two doctors who have researched the topic of “pharmacoequity” for a podcast, during which Dr. Utibe Essien, an assistant professor of medicine at the University of Pittsburgh, said this:

“I started med school a little over a decade ago, and we learned about disparities in health. We learned that black patients were more likely to have kidney disease, cancer, hypertension, diabetes, pretty much you name it. We saw that people who looked like me and my family members were more likely to have these conditions. And a lot of that conversation talked about different genes that we had, or, for some reason, there was something different about our bodies compared to other individuals. And then, the conversation shifted a little bit to the social determinants of health. And so, it’s because of the neighborhoods that certain communities have been redlined into, or because of differential access to resources, wealth, and goods.

“And I think [in some] ways we forgot about the conversation of what actually happens in the doctor’s office. And so, whether one of us shows up to the doctor with a new diagnosis of high blood pressure, a new diagnosis of diabetes[:] Are we likely, or as likely, to get the right prescription when we walk out of that office as someone else who came in who does not look like us, who has more wealth, who has more education?”

Costs, of course, drive many medical decisions, perhaps especially for pricey prescription drugs that poorer minorities cannot afford, experts say. But the U.S. medical system has failed to take a patient point of view in determining why prescribed drugs aren’t taken as doctors order them for black and brown patients in particular. The Harvard Business Review reported on one major health system’s urgent effort to improve patient outcomes by increasing adherence to medication orders:

“Our data showed that about 86% of [the plan’s] white members took their cholesterol medications (statins) as prescribed. Among black members, the rate was about 83%. Among Hispanic members, just 81%. Nearly 86% of our white members took oral diabetes medications (such as metformin) as prescribed. But among our black and Hispanic members, the rates were 81% and 84%, respectively.”

The health plan — which already had fewer issues with the big problem of drug costs, because so many of its patients already could access financial supports — recorded major reverses with a concerted campaign, including tying executive bonuses to changes. It pressured vendors and staff. It put a premium on listening to patients and trying to understand their issues, with HBR reporting:

“In all of these listening and interview sessions, we learned [that] non-adherent members often didn’t know which [prescription] benefits we offered that they could tap into. They often trusted nurses more than doctors. They had difficulty understanding providers who spoke English too rapidly or couldn’t answer questions in their native languages. Their cultural philosophy toward health care puts more emphasis on herbal treatments than medications. They had trouble getting transportation to their local pharmacy. And, most commonly, they simply did not understand what their prescribed medications were or how they would help improve their conditions.”

Doctors, hospitals, and researchers are finding disturbing racial biases in medical devices and tests, too. Electronic health records too often carry negative references to black patients and their behaviors as observed by white doctors and nurses, studies show. (*This underscores one of my major points about improving your health care by getting your own medical records and ensuring they are accurate and up-to-date.)

The now-familiar pulse oximeter, in which patients insert a finger to rapidly determine their blood oxygen levels by infrared light shined through the skin, has been found to be inaccurate for darker-skinned individuals. Researchers long had flagged the device’s problems, which became glaring during the pandemic. Studies suggest that black and brown coronavirus patients may have suffered due to flawed readings.

New technologies also may be carrying forward harder-to-detect racial inequities buried in their software and its reliance on such buzzy features as artificial intelligence (AI) and algorithmic decision-making (processes used in machines or software for calculations or problem-solving). In concrete terms, kidney experts dug into a promising diagnostic tool, only to see that it was rife with racial inequity, as the independent, nonpartisan KFF Health News reported:

“Black patients … are about four times as likely to have kidney failure as white Americans, and … make up more than 35% of people on dialysis but just 13% of the U.S. population. They’re also less likely to get on the waitlist for a kidney transplant, and less likely to receive a transplant once on the list. An algorithm doctors use may help perpetuate such disparities. It uses race as a factor in evaluating all stages of kidney disease care: diagnosis, dialysis, and transplantation. It’s a simple metric that uses a blood test, plus the patient’s age and sex and whether they’re black. It makes black patients appear to have healthier kidneys than non-black patients, even when their blood measurements are identical.

‘It is as close to stereotyping a particular group of people as it can be,’ said Dr. Rajnish Mehrotra, a nephrologist with the University of Washington School of Medicine. This race coefficient has recently come under fire for being imprecise, leading to potentially worse outcomes for black patients and less chance of receiving a new kidney.”

Expert advisory panels have urged a halt to this diagnostic and many hospitals have stopped using it.

But researchers, policy makers, politicians, as well as doctors, hospitals, and patients, need to know that AI and algorithms likely will only grow more prevalent — and safeguarding medical care from racial biases in health care technologies will be a big issue in the days ahead.