I am reading Angus Deaton's working paper, "What does the empirical evidence tell us about the injustice of health inequalities?" He notes the pronounced racial difference in health in the US.
In 2006, life expectancy at birth was 4.1 years less forAfrican Americans than for white Americans. There are also pronounced racial differences in treatment patterns, for example for cardiovascular disease... or knee arthoplasty...
Why does this happen?
The conventional explanation for these inequalities, endorsed by a 2002 report of the National Academies of Sciences..., is that the encounter between healthcare providers and patients leads to poorer treatment of African Americans by largely white providers.
If you accept this explanation for racial disparities in health care, then you may believe that the solution is to train culturally-competent health care providers, that is, providers who are able to interact effectively with persons from different cultures to deliver care.
Deaton does not dispute the cultural incompetence explanation, but
there is another, perhaps more obvious explanation, which is that African-Americans receive worse health care because the hospitals and clinics that serve them are of lower quality than the hospitals and clinics attended by other Americans. Hospitals in the US are run on something close to an apartheid basis, with few white patients in the hospitals that treat mostly African-Americans, and vice versa...; doctors and nurses are much less segregated, with many white doctors in “black” hospitals, and African-American doctors in “white” hospitals.
That is, because we live in a largely segregated society, race is highly correlated with geography. This point does not seem to be widely recognized in the literature on health disparities. (A technical implication is that a regression analysis of disparities that does not account for the spatial clustering of data is likely to omit an important variable.) This clustering matters because
The “black” hospitals have worse outcomes, are less well-provisioned, their pharmacies have fewer drugs, and their providers are less well-qualified... In consequence, people who live in cities with large African American populations—both African-Americans and whites who live in those areas—have poorer health.
Both the "doctors are culturally incompetent" and "hospitals serving blacks are under-resourced" causes for health disparities would represent gross injustices. Both could be true. My sense, however, is that the medical establishment and many disparities researchers have attached themselves to the cultural competence explanation. It is the kind of problem that seems like it could be fixed by HR department training, or continuing medical education. Providing facilities and providers of equal quality to everyone, regardless of race or income, would be both expensive and -- shall we say -- politically difficult.
h/t to Mike Foster, for helping clarify these matters for me.