What causes racial inequities in health?

post by Bill Gardner

The image is a recruitment letter from the Tuskegee experiment.

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.

 

Comments

[Kelly Kelleher]

Although both of these explanations are important sources of health CARE disparities, I believe there is strong evidence of an overall social discrimination/stress effect on many health disparities that is independent of the healthcare system.

[Bill Gardner]

I agree, Kelly, and Deaton also mentions this in the paper. I would say that, however, because it makes sense to me as a psychologist that the experience of racism would be exceptionally stressful, and because we have good evidence of the negative health effects of stress. It's less clear to me how we can directly test this idea.

[Daniel S. Goldberg]

Bill,

There is an ample and growing literature showing strong correlations between racism and health, even after controlling for confounding variables such as access to health care services. I have tremendous respect for Professor Deaton; indeed, I could not do the work I am doing without his wonderful scholarship on the subject, but the idea that racial health inequities are likely to be primarily caused by point-of-care inequalities is just as dubious as the idea that health inequities in general are primarily driven by access to health care services (or their absence).

Much of the excellent work on this subject flows from Nancy Krieger, David Williams, and Camara Jones, to name only a few. It is covered quite well in the award-winning documentary Unnatural Causes, and a number of causal mechanisms have been offered as explanations for the racism-health connnections, the allostatic load hypothesis only being the most obvious such account.

So, I want to echo Kelly's warning that we must be very careful to distinguish between inequities in health and inequities in health care. We can be concerned with both at the same time we grant one higher relative priority -- guess which one I favor prioritizing! -- and even as we interrogate the widely-assumed tight relationship between the two.

[uk.superiorpapers.com]

Much of the excellent work on this subject flows from Nancy Krieger, David Williams, and Camara Jones, to name only a few.