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(The online version of this article appears in two parts. Click here to go to part one.)

Race and Medical bias

ACCORDING to indoctrinologists, a mismatch in race between doctor and patient -- especially when the doctor is white and the patient is not -- may be enough to trigger biases that result in second-rate medical treatment and poorer health. Kenneth DeVille, of the Department of Medical Humanities at the East Carolina University School of Medicine, wrote in the August, 1999, issue of The American Journal of Public Health, "It is increasingly evident that African Americans and other minority patients have strong grounds for doubting both the goodwill and the color blindness of White medical practitioners." The American Medical Association's official newspaper, American Medical News, has stated that "a growing body of research reports that racial disparities in health status can be explained, at least in part, by racism and discrimination within the health care system itself." This is why, according to the Reverend Al Sharpton, of New York, health is the "new civil-rights battlefront" -- a sentiment echoed by other African-American leaders, including the Reverend Jesse Jackson and Julian Bond, the chairman of the National Association for the Advancement of Colored People.

In a 1998 radio address delivered during Black History Month, President Clinton said, "Nowhere are the divisions of race and ethnicity more sharply drawn than in the health of our people." Infant-mortality rates were twice as high for African-Americans as for whites, he said. Black men suffered from heart disease at nearly twice the rate of whites, and blacks were more likely than whites to die from breast cancer or prostate cancer. Overall, African-Americans were less likely to be routinely screened for cancer and less likely to get regular check-ups. Perhaps, the President said, one of the reasons for these disparities was "discrimination in the delivery of health services."

Elsewhere on the Web
Links to related material on other Web sites.

"Affirmative Action and Bioethics," by Kenneth A. DeVille (American Society for Bioethics and Humanities, Spring 2000)
"Although medical schools have not yet been specifically targeted, affirmative action programs are in danger there."

Given the history of systematic racial discrimination and segregation in the health-care system, lingering bias shouldn't be categorically ruled out. Black patients were once treated in separate and inferior hospital wards -- a policy that persisted at many hospitals in the Deep South until the 1960s. Routinely barred from joining hospital staffs and medical societies, black physicians started their own institutions to treat other blacks. As late as the mid-1960s several medical schools had restrictions against admitting black students.

Illustration by Laurent Cilluffo

Leslie Pickering Francis, a medical ethicist at the University of Utah, argues that in the absence of contrary evidence, "racism remains the presumptive cause of ... health care problems minorities face." This view is increasingly common. But the available evidence suggests that many race-related differences in health are not what they seem.

Cardiac catheterization, a procedure used to detect blockage in the coronary arteries (the vessels that feed blood to the heart itself), is frequently crucial in determining whether the arteries can be widened using a tiny balloon (a process known as balloon angioplasty) or whether some or all of them must be replaced in a bypass operation. Struck by the observation that black patients undergo catheterization less often than whites, Kevin A. Schulman, then at Georgetown University Medical Center, and others wanted to examine how doctors make the decision to refer patients for the procedure. They recruited 720 primary-care physicians at medical conventions and asked them to participate in a study of clinical decision-making. The physicians were not told that one purpose of the study was to explore how the race and sex of a patient might affect decisions, or that the researchers expected to find African-Americans and women referred for cardiac catheterization less frequently than white men.

The participants, most of whom were white, each watched one randomly selected video of a patient (actually, an actor wearing a hospital gown) who answered questions about chest pain and other relevant medical history. The viewers were given fictitious information about the actor-patients' insurance, occupations, and other personal history. The questions asked and the actors' responses, down to the gestures used when describing their symptoms, were all scripted to minimize inconsistencies. There were eight actors -- representing all the possible combinations of race (black or white), sex (male or female), and age (fifty-five or seventy) -- and 144 scenarios, one for every combination of these variables plus clinical variables: the nature of the chest pain, the level of coronary risk, and stress-test results.

The participants were asked whether the patients' complaints appeared to reflect heart disease or another kind of distress, such as indigestion, and to rate the likelihood that the patient had coronary-artery disease. According to the study, "women and blacks [in the study] were less likely to be referred for cardiac catheterization than men and whites." Men and whites were not referred about nine percent of the time; women and blacks were not referred about 15 percent of the time.

Schulman and his colleagues used a statistical analysis called odds ratio to report their findings -- the ratio of the odds in favor of blacks' being referred for catheterization to the odds of whites' being referred. The odds that blacks would be referred were 40 percent lower. Odds ratio is not the same as risk ratio, but the media equated them in referring to this study and reported that blacks had a 40 percent lower referral rate than whites. The statistic was widely circulated, and in discussing odds ratio, Schulman said in a Nightline interview the day before the study was published that "blacks were 40 percent less likely to be referred for cardiac catheterization compared to whites."

The study findings were presented in an article titled "The Effect of Race and Sex on Physicians' Recommendations for Cardiac Catheterization," published in The New England Journal of Medicine in February of 1999. Schulman and his colleagues wrote,

Our finding that the race and sex of the patient influence the recommendations of physicians independently of other factors may suggest bias on the part of the physicians. However, our study could not assess the form of bias. Bias may represent overt prejudice on the part of physicians or, more likely, could be the result of subconscious perceptions rather than deliberate actions or thoughts. Subconscious bias occurs when a patient's membership in a target group automatically activates a cultural stereotype in the physician's memory regardless of the level of prejudice the physician has.

The study received wide attention. On ABC's World News This Morning, Juju Chang told viewers, "How your doctor treats your heart may depend on the color of your skin.... The bias shows up in the diagnosis and doctors don't even realize it." Peter Jennings predicted on World News Tonight that the study would make "political waves" because it showed that "prejudice among doctors causes a gap in the quality of health care between blacks and whites." On Nightline, Ted Koppel set up the story like this: "Last night we told you how the town of Jasper, Texas, is coming to terms with being the place where a black man was dragged to his death behind a truck by an avowed racist. Tonight we're going to focus on [doctors] ... who would be shocked to learn that what they do routinely fits quite easily into the category of racist behavior."

Elsewhere on the Web
Links to related material on other Web sites.

"The Effect of Race and Sex on Physicians' Recommendations for Cardiac Catheterization," by Kevin A. Schulman, et al. (The New England Journal of Medicine, February 25, 1999)
"Our findings suggest that the race and sex of a patient independently influence how physicians manage chest pain."

"Misunderstandings about the Effects of Race and Sex on Physicians' Referrals for Cardiac Catheterization," by Lisa M. Schwartz, Steven Woloshin, and H. gilbert Welch (The New England Journal of Medicine, July 22, 1999)
Also, read a rebuttal to the February, 1999 New England Journal of Medicine article, "The Effect of Race and Sex on Physicians' Recommendations for Cardiac Catheterization."

Dr. Kevin Schulman: Minorities Less Likely to Get Best Cardiac Care (ABC News, February 25, 1999)
The transcript of a live online chat with Dr. Kevin Schulman.

"Health Care's Racial Divide," by George Strait (ABC News.com, February 25, 1999)
An article about Kevin Schulman and his study of racial bias in medical diagnoses.

Five months after the study appeared, The New England Journal of Medicine published a rebuttal, by Lisa M. Schwartz, Steven Woloshin, and H. Gilbert Welch, all physicians at the White River Junction Veterans Administration Hospital, in Vermont. The authors reviewed the original study data and explained that the actual average referral rates for three of the four groups were in fact the same. White men, white women, and black men were all referred by about nine out of ten doctors; black women were referred by about eight out of ten.

Schwartz, Woloshin, and Welch also expressed dismay that Schulman and his colleagues had focused discussion on two groupings (race and sex) rather than on the breakdown into four groups -- white men, black men, white women, and black women -- and that odds ratios were used in the study but reported by the media as risk ratios, thus overstating the findings. Equating odds ratios with risk ratios led to the "mistaken impression that blacks had a 40 percent lower probability of referral than whites, whereas in fact, the probability of referral for blacks was 7 percent lower," the authors wrote. "... These exaggerations serve only to fuel anger and undermine the trust between physicians and their patients." Schwartz and her colleagues were not alone in expressing concern; the NEJM editors published a note in the same issue expressing regret that odds ratios were used when risk ratios would have been clearer. "We take responsibility for the media's overinterpretation of [this] article," they wrote. "The evidence of racism and sexism in [the Schulman] study was overstated."

Illustration by Laurent Cilluffo

Nevertheless, Schulman persisted. "Our study will ... encourage the medical profession to seek ways to eliminate unconscious bias that may influence physicians' clinical decisions," he maintained in The New England Journal of Medicine. Schulman also met with the Congressional Black Caucus, at its invitation, and briefed members on bias in the health-care system. Paul Douglass, a cardiologist with the Morehouse School of Medicine, in Atlanta, supports Schulman's interpretation. "You can argue with statistics all day," he told USA Today. "We have to face the reality of our situation: there is a gender and racial bias."

Alternative Explanations

LESS eye-catching than accusations of bias are everyday aspects of clinical care that account for many of the recorded disparities among patient groups. For example, medical problems do not necessarily occur with the same frequency across races. As a 1999 report from the Henry J. Kaiser Family Foundation points out, "It should be noted that every differential in care is not necessarily a problem and the level of care obtained by whites may not be the appropriate standard for comparison." Consider these facts: uterine fibroid tumors and hysterectomies are more common in black women than in white women, and osteoporosis-related fractures, and thus hip replacements, are rarer. Limb amputation is more common among black patients, sometimes because thicker atherosclerosis in the leg makes it harder to perform limb-saving surgery.

African-Americans suffer strokes at higher rates than whites, yet the former are much less likely to undergo carotid endarterectomy, a procedure to unclog arteries in the neck. Racism? Unlikely. Whites tend to have obstructions in the large, superficial carotid arteries of the neck region, which are readily accessible to surgery, whereas blacks often have blockages in the branches of the carotids. These smaller vessels run deeper and farther up into the head, where surgery is riskier.

Elsewhere on the Web
Links to related material on other Web sites.

How Income, Race and Other Factors Influence Health: Papers and Publications
An overview of research and writing done by David R. Williams at the Institute for Social Research. Posted by the Academy for Health Services Research & Health Policy.

Thus even without cultural or socioeconomic obstacles an African-American patient at high risk for stroke is far less likely than a white patient to undergo carotid endarterectomy. Yet David R. Williams, a sociologist at the University of Michigan's Institute for Social Research, perceives disparities like these as evidence of bias. American Medical News quoted Williams in May of last year:
National studies, such as one that examined care at Dept. of Veterans Affairs medical facilities -- where all of the patients have comparable insurance coverage -- suggest "racial disparities in the quality of medical care do not merely reflect the behavior of a few bad apples," Williams said. "The evidence is too overwhelming and the pattern is too pervasive."

Williams and others seem not to consider a different interpretation: the patients' clinical needs, rather than the doctors' personal biases, are dictating the care. If not for concern about their patients (many of whom are treated in private hospitals and have health insurance), why wouldn't physicians perform a procedure for which they would be paid?

Indoctrinologists are making steady inroads in medicine. They now sit at the helms of professional associations and hold impressive posts at schools of public health; they have changed medical-school admissions criteria; they serve on the boards of respected academic journals. They are outspoken, sometimes insistent participants in many legislative and political debates. Their numbers and influence are growing. Most disturbing, I find, is their stubborn reluctance to acknowledge that each person has some responsibility for preserving his or her own health -- an attitude that threatens to reverse the gains made by public health in the past century.

From the archives:

"The AIDS Exception: Privacy vs. Public Health," by Chandler Burr (June 1997)
It's time to stop granting "civil rights" to HIV -- and to confront AIDS with more of the traditional tools of public health.

From Atlantic Unbound:

Roundtable: "AIDS -- Privacy vs. Public Health" (June 3, 1997)
The AIDS epidemic is one of the most politically and morally charged issues of our day. The Atlantic's Cullen Murphy convenes a panel of experts and asks whether we can wage effective war on the disease and protect its victims' civil rights.

I am by no means the first to note the existence of the indoctrinologists. The medical economist Robert G. Evans commented in Why Are Some People Healthy and Others Not? (1994), "For [those on the left], health differentials are markers for social inequality and injustice more generally, and are further evidence of the need to redistribute wealth and power, and restructure or overturn the existing social order." An example of what Evans is talking about comes from Sally Zierler, of Brown University's Department of Community Health, who sees AIDS as "a biological expression of social inequality." At a lecture Zierler gave at the 1998 annual meeting of the American Public Health Association, I copied down some of her recommendations for changing the wage structure, which is one of her prescriptions for curbing the AIDS epidemic: cap salaries of CEOs, eliminate corporate subsidies, and strengthen labor unions.

Tuberculosis is another disease that one might call a biological expression of social inequality, because it primarily affects the poor, the homeless, and the addicted. Yet it was New York City's hard-nosed decision, in the early 1990s, to require that everyone who needed medication take it daily, in front of a health worker, that checked the spread of tuberculosis.

Ironically, indoctrinologists, who want revolution in the name of health, have been quick to condemn practical hygiene efforts as dangerous social intrusion. As Paul Starr noted in his sweeping history The Social Transformation of American Medicine (1982),

The recent anti-Progressive historians, including both Marxists and liberals, tend to reclassify as social control events like the conquest of disease that were once properly regarded as historic achievements of human freedom. They remember the public health nurse who instructed mothers in infant hygiene as a kind of surreptitious agent of the police, insinuating bourgeois ideals into the authentic culture of the working class.

Some of the more counterproductive manifestations of this revolution-in-waiting can be reversed overnight. I suggest, for example, that the federal government cease funding research into the effects of "powerlessness," "classism," and "racism" on health; these are virtually impossible to study in quantitative fashion. I also think that medical schools should stop using racial preferences in admitting students, in light of ample evidence that students admitted noncompetitively have academic trouble in medical school and little evidence that minority patients fare better when treated by minority physicians -- a standard justification for racial preferences.

These steps would be a good beginning, but they are unlikely to halt a movement of such broad scope. We must remain clear-eyed about the fact that uneven access to medical services, disparate knowledge of good health practices, and patients' own attitudes about their health -- not discrimination and bias -- underlie the vast majority of differences in health outcomes. Moreover, we must concentrate on the problems that the health-care profession can actually do something about: preventing and alleviating the nation's physical -- not its social -- distress.

(The online version of this article appears in two parts. Click here to go to part one.)

Sally Satel is a psychiatrist at a drug-treatment clinic in Washington, D.C., and a lecturer at the Yale University School of Medicine. Her article in this issue is adapted from her book P.C., M.D.: How Political Correctness Is Corrupting Medicine, to be published this month.

Illustrations by Laurent Cilluffo.

Copyright © 2001 by The Atlantic Monthly Company. All rights reserved.
The Atlantic Monthly; January 2001; The Indoctrinologists Are Coming - 01.01 (Part Two); Volume 287, No. 1; page 59-64.