If we are anthro-culturally different from our patients and we see our patients through the lenses of our biases, we risk not understanding their values, expectations of their care, and their needs. —Dana M. Thompson, MD, MS
Explore This IssueNovember 2019
Quoting Dr. Kissick, Dr. Thompson said, “Tradeoffs are inevitable regardless of the size of the triangle, and they’re all choices that society must make.” She added, “When we look at how we view healthcare as Americans, are we okay with this concept?” She pointed to unsustainable costs, quality that lags behind other comparable countries, and the inequitable distribution of healthcare access. “Populations who are going to be at greatest risk are those that we have biases against based on race, ethnicity, sex, sexual identification, age, disability, socioeconomic status, and where we live,” she said.
Market Justice vs. Social Justice
Dr. Thompson pointed out that the guiding principles of care access can fall under market justice (the belief that healthcare access and allocation is a reward based on personal effort and achievement, akin to private insurance) or social justice (the belief that access and allocation is a social resource and ability to pay is inconsequential for receiving care, akin to publicly funded insurance). “The reality of the United States is our payment system is a combination of both,” she said. “We have to recognize that the outcomes are not always equitable and ask, is there parity in the value of care when comparing payment systems?”
Impacts on Health Equity
For African Americans, the long history of inequity and healthcare inequity stretches back to slavery. “The transport itself from Africa to the New World remains one of the best examples of the ability of one center of humanity to destroy the health of another,” she said. “So the fact that the African American population is the least healthy ethnic group in the United States is not due to chance alone. We have to remember our history.”
That history continued with segregation, including “separate but equal” hospitals for African Americans and segregated medical schools, and it continues today with a deeply rooted distrust of the healthcare system based on cases that include that of Henrietta Lacks, whose cervical cancer cells were used without her knowledge or consent to become one of the most important cancer cell lines in the history of medical research.
Capitalism has also been a long-time deterrent to parity and equity in healthcare. “To really understand the brutality of American capitalism, you have to start on the plantation. While cotton may have been king and helped our economic development as a country, it was done on the backs of slaves,” Dr. Thompson said.
Race and socioeconomic status comprise the social determinants of health in American healthcare delivery models, and other factors play a part too. One of the strongest predictors of life expectancy, Dr. Thompson said, is whether a person graduated high school, which varies dramatically among class, race, and other ethnic divisions. It also determines who goes to college or vocational school, ultimately becomes employed, and lives a healthy life.
Ethnicity and culture, she said, can affect a patient’s attitude toward the idea of even visiting a physician at all. Lack of reliable transportation in urban areas, and long-distance transportation challenges in rural areas, can delay care, while lack of financial resources can limit access to healthy food and lead to poor nutrition and limited healing. “If we look in the city that we’re in right now, New Orleans,” she said, “you will see that there is more than a 25-year difference between life expectancy depending on which area of the city that you live.”
She pointed out that Black infants and children in poor rural communities have a three times higher mortality rate compared with those in affluent areas. Uninsured, underinsured, and rural patients tend to present late with head and neck cancer. Children from lower socioeconomic backgrounds are more likely to present with more severe complications of bacterial sinusitis. And children with hearing loss from certain geographic regions or ethnic backgrounds are significantly delayed in diagnosis and treatment for hearing. “Roots of inequity are driven by the socioeconomic factors that impact marginalized populations and our biases and our attitudes toward them,” she said.