A large body of research has shown the important role of culture and environment: For a review article on the subject, see Nancy Adler and Katherine Newman, Socioeconomic Disparities in Health: Pathways and Policies, Health Affairs 2002; 21(2):60–76.
such factors have a direct effect on health disparities: For detailed discussions on the ways that socioeconomic class and race intersect with respect to health, see Stephen Isaacs and Steven Schroeder, Class—The Ignored Determinant of the Nation’s Health, New England Journal of Medicine 2004; 351:1137–1142; Ichiro Kawachi et al., Health Disparities by Race and Class: Why Both Matter, Health Affairs 2005; 24:343–352; and David Williams and Pamela Braboy Jackson, Social Sources of Racial Disparities in Health, Health Affairs March/April 2005; 24:325–334.
There are many barriers: For discussions on the various factors that discourage physician-based nutrition and exercise counseling, see Robert Kushner, Barriers to Providing Nutrition Counseling by Physicians: A Survey of Primary Care Practitioners, Preventive Medicine 1995; 24:546–552; Gary Foster et al., Primary Care Physicians’ Attitudes About Obesity and Its Treatment, Obesity Research 2003; 11:1168–1177; and Jian Huang et al., Physician’s Weight Loss Counseling in Two Public Hospital Primary Care Clinics, Academic Medicine 2004; 79:156–161.
sense that nutrition talk is better left to dieticians: In a 2003 survey of more than 600 primary care physicians, a little less than half reported feeling confident in their ability to prescribe a weight loss program for their patients. See Gary Foster et al., Primary Care Physicians’ Attitudes About Obesity and Its Treatment.
experience has made many doctors cynical about patient behavior and the likelihood for change: For brief, thoughtful articles that explore this subject, see Sandeep Jauhar, “No Matter What, We Pay for Others’ Bad Habits,” New York Times, March 29, 2010; Pauline Chen, “Getting Patients to Take Charge of Their Health,” New York Times, January 12, 2012; and Danielle Ofri, “When the Patient Is ‘Noncompliant,’” New York Times, November 15, 2012.
basics of secondary prevention: Primary prevention involves protecting healthy people from developing a disease or suffering an injury, for example, receiving a vaccine or wearing a seat belt. Secondary prevention takes place after an illness has occurred, such as taking daily aspirin following a heart attack or stroke. In Adrian’s case, he had already experienced a mini-stroke, so the neurologists’ recommendations were part of a secondary prevention strategy.
black people, who are 50 percent more likely than whites to be obese: For data on higher obesity rates among black people, especially among women, see Liping Pan et al., Differences in Prevalence of Obesity Among Black, White, and Hispanic Adults, United States 2006–2008, Morbidity and Mortality Weekly Report 2009; 58 (27):740–744; http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5827a2.htm#tab1.
Given the impact that physician advice can have on patient behavior: For example, a 2011 study concluded that physician counseling on obesity was associated with greater efforts by patients to lose weight; see Robert Post et al., The Influence of Physician Acknowledgment of Patient’s Weight Status on Patient Perceptions of Overweight and Obesity in the United States, Archives of Internal Medicine 2011; 171:316–321. A 2000 study found that physician advice was associated with greater efforts by patients to quit smoking and make positive changes in diet and physical activity, see Matthew Kreuter et al., How Does Physician Advice Influence Patient Behavior? Evidence for a Priming Effect, Archives of Family Medicine 2000; 9:426–433. An older study looking at cigarette smoking reached similar conclusions, see Erica Frank et al., Predictors of Physicians’ Smoking Cessation Advice, Journal of the American Medical Association 1991; 266:3139–3144.
Why was making a long-term healthy change so difficult?: For perhaps the best overview and discussion of the individual, health system, and doctor-patient barriers to effective blood pressure control for African Americans, see Lisa Cooper, A 41-Year-Old African American Man with Poorly Controlled Hypertension, Journal of the American Medical Association 2009; 301 (12):1260–1272.
Researchers have speculated that strong cultural influences … might make it more difficult for black patients to follow a healthy diet: For a recent review on the subject, see Dawn Epstein et al., Determinates and Consequences of Adherence to the Dietary Approaches to Stop Hypertension Diet in African-American and White Adults with High Blood Pressure: Results from the ENCORE Trial, Journal of the Academy of Nutrition and Dietetics 2012; 112:1763–1773.
A 2012 study: Ibid. For a personal perspective on the subject from a black physician, see Khaalisha Ajala, “How Soul Food Stymies African-Americans’ Low Salt Efforts,” ABC News medical unit, available at: http://abcnews.go.com/Health/soul-food-stymies-african-americans-low-salt-efforts/story?id=17265086&singlePage=true.
surveys have indicated that black people are more accepting of—and in some cases indicate a preference for—heavier body types: See for example, Rashida Dorsey et al., Racial/Ethnic Differences in Weight Perception, Obesity 2009; 17:790–795.
The Meharry-Hopkins Cohort study explored our health dilemma on a larger scale: See John Thomas et al., Cardiovascular Disease in African-American and White Physicians: The Meharry Cohort and Meharry-Hopkins Cohort Studies, Journal of Health Care for the Poor and Underserved 1997; 8:270–283.
10: BEYOND RACE
the first black student to attend medical school at Duke: For profiles of Delano Meriwether, see “Medical Miracle: Meriwether Beats All Odds on Track & in Life,” (New York) Daily News, January 14, 2007; Sandy Treadwell, “Hey, I Can Beat Those Guys,” Sports Illustrated, January 18, 1971; and Robert Boyle, “Champion of the Armchair Athletes,” Sports Illustrated, February 22, 1971. Meriwether was on the cover of this issue.
Some critics expressed reasonable concerns: Many critiques of the Affordable Care Act (ACA) come across as overtly partisan. For authors who seem to take a balanced approach in weighing the pros and cons of the ACA, see Darshak Sanghavi, “Don’t Celebrate Yet,” Slate, June 28, 2012; Steven Brill, “Bitter Pill: Why Medical Bills Are Killing Us,” Time, February 20, 2013; Tina Cheng and Paul Wise, Promise and Perils of the Affordable Care Act for Children, Journal of the American Medical Association 2014; 311:1733–1734; and Mehroz Baig, “A Physician’s Take on the Affordable Care Act, Interview with Dr. Victoria Sweet,” Huffington Post, April 15, 2014; http://www.huffingtonpost.com/mehroz-baig/a-physicians-take-on-the-_b_5155995.html.
North Carolina, like its neighboring Southern states, largely opposed Obamacare and rejected the law’s provision: Along with extending private insurance coverage to individuals through a variety of mechanisms, the Affordable Care Act relies on a large expansion of Medicaid, a joint federal-state program for the poor. In the 2012 U.S. Supreme Court decision, National Federation of Independent Business v. Sebelius, the court allowed individual states to decline the expansion of Medicaid. In what largely mirrors (although not perfectly) the red state–blue state divide in recent elections, the blue states have mostly chosen to opt-in to the Medicaid expansion while the red states have mostly elected to opt-out of the expansion. North Carolina, under the leadership of Governor Pat McCrory (R) and a Republican legislature, has shifted to the “red state” ledger since President Obama narrowly won the state in the 2008 election.
Analysis from the Kaiser Family Foundation: For data on Medicaid expansion, see The Coverage Gap: Uninsured Poor Adults in States That Do Not Expand Medicaid—Issue Brief 8505-02, Kaiser Family Foundation, April 2, 2014; http://kff.org/health-reform/issue-brief/the-coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid.
While I agreed that having Medicaid was better than having no health insurance: The effectiveness of Medicaid in improving health has yielded some interesting results. See Benjamin Sommers et al., Mortality and Access to Care Among Adults After State Medicaid Expansions, New England Journal of Medicine 2012; 367:1025–1034. This study found that state Medicaid expansions in New York, Maine, and Arizona were “signi
ficantly associated with reduced mortality as well as improved coverage, access to care, and self-reported health.” Another study found that Medicaid recipients in Oregon showed no significant improvement in measured physical outcomes (blood pressure, cholesterol, glycated hemoglobin levels), but exhibited lower rates of depression and reduced financial strain after receiving Medicaid. Katherine Baicker et al., The Oregon Experiment—Effects of Medicaid on Clinical Outcomes, New England Journal of Medicine 2013; 368:1713–1722. Further study in this area is needed. One future approach might involve comparing various health and financial parameters from a state that accepted Affordable Care Act Medicaid expansion with a similar state that declined the expansion.
The problems take three forms: For a journalistic-style overview of the multiple factors that are involved with health disparities, see Chelsea Conaboy, “Racial and Ethnic Disparities in Health—and How to Fix Them,” National Journal, March 13, 2014. Using Philadelphia as the focus for the article, Conaboy concluded: “the main obstacle to good health is poverty.” See also Peter Kilborn, “Nashville Clinic Offers Case Study of Chronic Gap in Black and White Health,” New York Times, March 21, 1998. In an interview with black doctors treating black patients at Meharry Medical College, the doctors there felt that health disparities were “a socioeconomic thing,” and that in order to reverse them “you have to reverse a whole way of being.” For a narrative and historical look at the subject, see Fitzhugh Mullan, Still Closing the Gap, Health Affairs 2009; 28:1183–1188.
And it is here that the Affordable Care Act: For a book-length examination written in support of the Affordable Care Act, see Ezekiel Emanuel, Reinventing American Health Care (New York: Public Affairs, 2014). For a similar perspective written in shorter form, see the writings of Harvard surgeon and medical writer Atul Gawande: “Now What?” The New Yorker, April 5, 2010; “Something Wicked This Way Comes,” The New Yorker, June 28, 2012; and “States of Health,” The New Yorker, October 7, 2013.
Other medical writers, while supportive of the core feature of expanding health insurance coverage, have voiced skepticism about certain aspects of the Affordable Care Act. See for example, Darshak Sanghavi, “Bringing Down the House,” Slate, June 23, 2009, and Darshak Sanghavi, “Grand Illusion,” Slate, January 20, 2010. In both articles, Sanghavi articulates his doubts that an individual insurance mandate will be effective in extending affordable health care coverage to the uninsured. See also Jerome Groopman, “Health Care: Who Knows ‘Best’?” New York Review of Books, February 11, 2010, and Jerome Groopman and Pamela Hartzband, “Sorting Fact from Fiction on Health Care,” Wall Street Journal, August 31, 2009. Groopman raises concerns about whether the health care law’s early emphasis on expert-based guidelines and “best practices” might interfere with doctor-patient health care decision making.
One side has taken a race-focused approach: For articles on cultural competency, see Joseph Betancourt, Cultural Competence—Marginal or Mainstream Movement, New England Journal of Medicine 2004; 351:953–955, and Sunil Kripalani et al., A Prescription for Cultural Competence in Medical Education, Journal of General Internal Medicine 2006; 21:1116–1120. For a related paper that focuses on physician workforce aspects, see Fitzhugh Mullan et al., The Social Mission of Medical Education: Ranking the Schools, Annals of Internal Medicine 2010; 152:804–811. This article ranks the quality of schools based on the percentages of graduates who practice primary care, work in underserved health areas, and who are underrepresented minorities.
The other method is more race-neutral: For writings that take a more race-neutral approach to improving the health of black patients, see Jonathan Glick and Sally Satel, The Health Disparities Myth: Diagnosing the Treatment Gap (Washington, D.C.: American Enterprise Institute for Public Policy Research, 2006), and David Mechanic, Policy Changes in Addressing Racial Disparities and Improving Population Health, Health Affairs 2005; 24:335–338. Mechanic asserts: “it is important to think carefully about interventions and not assume that initiatives directed at reducing such disparities bring the largest gains in advancing the health of black citizens. Increasingly, much of the policy discussion is focused on whether disparities are increasing or decreasing and less so on which interventions can bring the largest health gains for all.” Finally, see Darshak Sanghavi, “Color Bind: How to Fix Racial Disparities in Medical Care,” Slate, August 14, 2009. Sanghavi offers evidence to assert that “universal quality-improvement plans coupled with publicly reported measures are the best way to cut health disparities,” and that “these kinds of race- and class-blind interventions are arguably the only ones proven to reduce disparities on a meaningful scale.”
On the individual level: For an interesting take on the patient’s perspective, see Sherrie Kaplan and Sheldon Greenfield, The Patient’s Role in Reducing Disparities, Annals of Internal Medicine 2004; 141:222–223. The authors argue against doctor-patient race matching and cultural competence training as panaceas to remedy disparities, asserting that “focusing solely on physicians and the clinical setting is meeting only half the challenge.” They propose formal “patient training programs” that teach minority patients to “make the most of those brief office visits” with physicians.
Ongoing public and private efforts to encourage healthier lifestyles: The most well-known recent campaign in this realm has been Michelle Obama’s Let’s Move! initiative. It launched in 2010 with the ambitious goal of solving the problem of childhood obesity within a generation. The program organizes its work around five pillars: giving kids a healthy start in life; empowering parents and caregivers to make healthy choices for kids; improving school food; ensuring access to healthy food; and promoting physical activity. It is not surprising that this campaign has been criticized by the political right, which has raised concerns about excessive government interference. But it also has critics on the left, who argue that it doesn’t go far enough to address the role of income inequality in obesity and other health-related disparities.
there are clear signs of progress: For data on reductions in teen pregnancy, see National Vital Statistics Report, Births: Final Data for 2010 61, no. 1 (August 2012). For data highlighting a lower infant mortality rate among blacks and an increased life expectancy, see National Vital Statistics Report. Deaths: Final Data for 2010 61, no. 4 (May 2013). For information on the reduction in violent crime among black people since the mid-1990s, see Erika Harrell, “Black Victims of Violent Crime,” Bureau of Justice Statistics, August 2007.
Selected Bibliography
BOOKS ON MEDICAL PRACTICE AND TRAINING
Ansell, David. County. Chicago: Academy Chicago Publishers, 2011.
Austin, Paul. Something for the Pain. New York: W.W. Norton, 2008.
Black, Keith. Brain Surgeon. New York: Wellness Central, 2009.
Brawley, Otis. How We Do Harm. New York: St. Martin’s Press, 2011.
Carson, Ben. Gifted Hands. Grand Rapids: Zondervan, 1990.
______. The Big Picture. Grand Rapids: Zondervan, 1999.
Chen, Pauline. Final Exam. New York: Knopf, 2007.
Cook, Robin. The Year of the Intern. New York: Harcourt, 1972.
Davis, Sampson. Living and Dying in Brick City. New York: Spiegel & Grau, 2013.
Emanuel, Ezekiel. Reinventing American Health Care. New York: Public Affairs, 2014.
Gawande, Atul. Complications. New York: Henry Holt and Company, 2002.
______. Better. New York: Henry Holt and Company, 2007.
______. Being Mortal. New York: Henry Holt and Company, 2014.
Groopman, Jerome. The Measure of our Days. New York: Viking Penguin, 1997.
Jauhar, Sandeep. Intern. New York: Farrar, Strauss, and Giroux, 2008.
______. Doctored. New York: Farrar, Strauss, and Giroux, 2014.
Klass, Perri. A Not Entirely Benign Procedure. New York: Putnam, 1987.
Konner, Melvin. Becoming a Doctor. New York: Viking Adult, 1987.
Lerner, Barron. The Good Doctor. Boston: Beacon Press, 2014.<
br />
Marion, Robert. Intern Blues. New York: William Morrow and Company, 1989.
______. Learning to Play God. New York: Addison-Wesley, 1991.
Mukherjee, Siddhartha. The Emperor of All Maladies. New York: Scribner, 2010.
Mullan, Fitzhugh. White Coat, Clenched Fist. New York, Macmillan, 1976.
Nuland, Sherwin. How We Die. New York: Knopf, 1994.
Ofri, Danielle. Singular Intimacies. Boston: Beacon Press, 2003.
______. Incidental Findings. Boston: Beacon Press, 2005.
______. What Doctors Feel. Boston: Beacon Press, 2013.
Reilly, Brendan. One Doctor. New York: Atria Books, 2013.
Rothman, Ellen. White Coat. New York: William Morrow and Company, 1999.
Shem, Samuel. House of God. New York: Richard Marek Publishers, 1978.
Shilts, Randy. And the Band Played On. New York: St. Martin’s Press, 1987.
Sweet, Victoria. God’s Hotel. New York: Riverhead, 2012.
Verghese, Abraham. My Own Country. New York: Simon & Schuster, 1994.
Vertosick, Frank. When the Air Hits Your Brain. New York: W. W. Norton, 1996.
White, Augustus. Seeing Patients. Cambridge: Harvard University Press, 2011.
BOOKS ON RACIAL AND CLASS THEMES
Carter, Stephen L. Reflections of an Affirmative Action Baby. New York: Basic Books, 1991.
Cashin, Sheryll. The Failures of Integration. New York: Public Affairs, 2004.
______. Place, Not Race. Boston: Beacon Press, 2014.
Cosby, Bill, and Alvin Poussaint. Come On People. Nashville, Thomas Nelson, 2007.
Cose, Ellis. The Rage of a Privileged Class. New York: Harper Collins, 1993.
Gasman, Marybeth. The Morehouse Mystique. Baltimore: Johns Hopkins University Press, 2012.
Gates, Henry Louis, Jr. Colored People. New York: Knopf, 1994.
Golden, Daniel. The Price of Admissions. New York: Crown, 2006.
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