Health Care Disparities and Diversity in Emergency Medicine
Key Points• The U.S. population is changing rapidly and becoming more diverse.
• Improving access to care for racial and ethnic minorities has not proved effective in ameliorating disparities in health care.
• A diverse workforce that mirrors the patient population is a key and important step toward reducing health care disparities.
• Cultural competency helps health care providers understand how to approach patients from different backgrounds by improving communication and building trust in the doctor-patient relationship.
• Cultural competency is as important as clinical competency to successful practice of emergency medicine.
Introduction
As the globalization of trade, technology, investment, and migration create a more diverse U.S. population, we are increasingly becoming aware of disparities in economics, health care, and human rights. Our nation was founded on the concept that “all men are created equal,”1 and equal treatment and equal access are the goals toward which we strive. Nowhere else in medicine is the commitment to equality as obvious as it is in our emergency departments (EDs), where the sole criteria for moving to the front of the line is severity of illness. Other specialties now restrict the days and hours during which they are available to patients and tell their patients at hospital discharge to go the ED if they have any problems or concerns. Fewer private physicians are welcoming indigent patients into their practices. Changes in the economy have resulted in a significant increase in the percentage of uninsured.2 Only the ED provides medical care 24 hours a day, 365 days a year for every patient with any chief complaint. As advocates for our patients, emergency physicians (EPs) are at the forefront of the promotion of diversity and elimination of disparities in health care not just at home but throughout the world as well.
An awareness of the history of disparities in access to quality health care (Table 1), the benefits of clinical research (Table 2), and medical education and emergency medicine (EM) practice (Box 1) will create a contextual framework within which the reader can appreciate all that has been accomplished, as well as the tasks that remain, as we work toward the ideals of diversity and cultural competency.
Table 1 History of Health Care Disparities
| 1619-1865 | Contaminated drinking water led to frequent outbreaks of cholera, typhoid, hepatitis, malaria, and yellow fever and the transmission of intestinal parasites among slaves.3 Slaves develop a system of care involving indigenous herb root doctors and midwives.4 |
| 1824 | The Bureau of Indian Affairs is established and provides limited health care to Native Americans on reservations.5 |
| 1852 | The first hospital for the care of Negroes is opened (Jackson Street Hospital, Augusta, Georgia).6 |
| 1862 | The only government-funded hospital for Negroes, Freedmen’s Hospital in Washington, DC, is established.7 |
| 1948 | Executive Order 9981 mandates the integration of Veterans Administration hospitals.8 |
| 1955 | The Indian Health Service is commissioned.9 |
| 1965 | The Johnson administration announces that federal Medicaid and Medicare payments will be denied to segregated hospitals.10 |
| 1990 | A metaanalysis of 485 articles confirms that migrant health care is confined almost exclusively to charity migrant clinics and virtually nothing is known about the health status of the workers.11 |
| 2004 | At every age, blacks have higher blood pressure than nonblacks do.12 |
| 2005 | A total of 16.5% of American Indians, 10.4% of Hispanics, and 6.6% of whites are diabetic.13 |
| 2006 | African Americans are more likely to die of coronary artery disease than whites are. They and Hispanics are less likely to be offered bypass or angioplasty. Blacks have worse cancer survival rates, are more likely to undergo amputation for complications of diabetes, and are less likely to be referred for transplantation evaluation than whites are. Hispanics and Native Americans are least likely to be offered cholesterol management services.14 |
| 2009 | Of all patients in whom human immunodeficiency virus infection was diagnosed this year, 52% are black.15 |
| 2010 | Twenty percent of the population lives in rural areas, where only 9% of physicians practice.16 |
Table 2 History of Disparities in Research
| Nazi human experimentation: 1938-1945 | Josef Mengele, MD, was one of the notorious physicians who performed burning, boiling, freezing, beating, hanging, and poisoning experiments on human prisoners of war who were predominantly racial and ethnic minorities in Europe.17 |
| Tuskegee Study of Untreated Syphilis in the Negro Male: 1932-1972—Taliaferro Clark, MD | The U.S. Public Health Service conducted a study of the natural course of syphilis in black males, often not informing them of their diagnosis and deliberately preventing them from seeking and obtaining treatment when penicillin became widely available.18 |
| Willowbrook: 1963-66 | Saul Krugman, PhD, studied the effects of gamma globulin on hepatitis by deliberately infecting mentally handicapped children with the virus.19 |
| Nuremberg Code: 1948 | This code arose from the trials of Nazis for crimes against humanity; it addressed consent by and protection of subjects of human research.20 |
| Declaration of practice, Helsinki: 1964 | The World Medical Association established good clinical practices in human research (standards revised in 1975, 1983, 1989, 1996, 2000, 2002, 2004, and 2008).21 |
| Belmont Report: 1979 | This report established boundaries between practice and research and basic ethical principles of human research.22 |
Box 1 History of Disparities in Medical Education
• 1783: Dr. James Durham, a former slave, becomes the first African American physician. He sets up practice in New Orleans after an apprenticeship training.
• 1837: Dr. James McCune Smith is the first African American to obtain an MD degree. He has to go to the University of Glasgow to do so. He sets up practice in New York City.
• 1847: Dr. David J. Peck is the first African American to graduate from a U.S. medical school (Rush Medical College).
• 1849: Two African American men receive MD degrees from Bowdoin College, Maine.
• 1850: Thirteen African American doctors are practicing: 9 in New York City and 4 in New Orleans.
• 1857: Dr. Elizabeth Blackwell becomes the first woman to graduate from a U.S. medical school and founds the New York Infirmary for Women and Children.
• 1864: Dr. Rebecca Lee Crumpler, a former nurse, becomes the first African American woman to earn a medical degree in the United States.23
• 1867: Dr. Blackwell founds the Women’s Medical College of Pennsylvania
• 1868 and 1876: Eight black medical schools were established; only two are still open: Meharry, Tennessee (1876), and Howard, Washington DC (1868).
• 1889: Dr. Susan La Flesche Picotte is the first American Indian woman to earn an MD degree; she receives it from the Women’s Medical College of Pennsylvania.
• 1890: There are 909 African American doctors, as compared with 1734 in 1900 and 4500 in 1960.
• 1891: Dr. Daniel Hale Williams opens the first black-owned hospital (Provident Hospital in Chicago).
• 1905: Being denied membership in “mainstream” medical associations, Dr. Williams establishes the National Medical Association.
• 2009: Dr. Marcus L. Martin is appointed Vice President of the University of Virginia after holding the posts of Chairman, Department of Emergency Medicine, and Assistant Dean of the School of Medicine. Dr. Martin is the first African American President of the Society for Academic Emergency Medicine and the first African American President of the Council of Emergency Medicine Residency Directors.
History of Health Care Disparities in the United States
The word disparity, simply defined, implies the lack of parity or the “state of being dissimilar or unequal.”24 America, historically referred to as “the melting pot,” is a nation whose culture is based on dissimilarity but, ostensibly, on equality. The “melting pot” concept implies that disparities melt away as the nation comes to embody a mixture of qualities from the cultures of all people who live in the United States,25 thus giving rise to the equality envisioned by the framers of our Constitution. However, no republic in recorded history has ever been able to embody the equality on which it is theoretically based, and the United States is no exception. The words of the Bill of Rights, “all men are created equal,” were rather promptly contradicted by our Constitution’s Three-Fifths Compromise and Enumeration Clause.26 Parity in representation was not granted to African Americans until the 15th Amendment was passed in 1870, and women were denied suffrage until passage of the 19th Amendment in 1920. Our policies continue to reflect the wish to achieve equality within the realities of our imperfect history.
Disparity in access to care is as old as America itself. Typically, plantation slaves lived in quarters where contaminated drinking water led to frequent outbreaks of cholera, typhoid, and hepatitis and facilitated the transmission of intestinal parasites. Food scraps and human excrement in stagnant water bred the mosquitoes that transmitted malaria and yellow fever.3 Slave owners usually performed the services of leaching and blistering and administered home medications, with a physician being sent for only as a last resort. Slaves came to distrust the care rendered by owners and overseers and developed their own system of care involving herb root doctors and midwives.4 It was not until 1852 that hospital care became available to slaves, when the Jackson Street Hospital was founded in Augusta, Georgia, by a white physician, Dr. Henry Fraser Campbell of the University of Georgia School of Medicine. In 1862, Freedmen’s Hospital in Washington, DC, became the only government-funded hospital for Negroes.7 Hospitals remained segregated until Executive Order 9981, which mandated the integration of Veterans Administration hospitals, was signed by President Truman in 1948,8 and the administration of President Johnson forced integration in 1965 by denying federal Medicaid and Medicare dollars to segregated hospitals.10
Access to care for members of American Indian tribes was even more restricted. The Bureau of Indian Affairs, established in 1824 by then Secretary of War John C. Calhoun, provided limited health care to the original Americans who had been segregated to reservations. The scope of care was improved when the Indian Health Service was commissioned in 1955,9 and access to all hospital care was afforded under the 1965 Medicare and Medicaid legislation.
As recently as 1990, a metaanalysis of 485 articles confirmed that migrant health care was confined almost exclusively to charity migrant clinics, with virtually nothing being known about the health status of the workers.11 Today, lack of access to care plagues America’s rural areas, where 20% of our citizens are served by only 9% of our physicians. Economic recession and loss of employment have resulted in a decreased number of insured patients to support a rural medical practice.16
History of Disparity in Research
With the advent of antibiotics, vaccines, and other drugs to treat human ailments, the findings of basic science became applicable to the medical care of human patients, and with this came the advent of clinical research. The scientific method was applied to medicine as physician-scientists sought to understand the processes of disease and the best ways to treat them. Clinical research proceeded without regulation, and despite the fact that most scientists conducted their work with the good of their patients as the highest goal, several experiments overtly violated human decency and human rights. The most barbaric of all human experimentation was that conducted in the Nazi death camps during World War II (see Table 2). These experiments were, in fact, so unthinkable that physicians and the public saw this as an aberration and did not believe that doctors could ever violate human rights in any other circumstances. However, in 1963, Saul Krugman of the New York University School of Medicine infected severely mentally retarded children at the state-supported Willowbrook School with live hepatitis B virus, both orally and by injection, to test the effect of gamma globulin on progression of the disease (see Table 2). Dr. Krugman had obtained written consent by mail from the mothers of his subjects, but the consent was woefully inadequate in explaining that the children would be deliberately infected with virus. When the Tuskegee experiments were brought to national attention by Jean Heller of the Associated Press in 1972,27 there was a public outcry against experimentation conducted by the U.S. Public Health Service with tax dollars that violated the rights of U.S. citizens. Both Dr. Krugman and Dr. Taliaferro Clark (the principal investigator on the Tuskegee experiment) justified their actions by stating that these were merely “studies in nature” following the natural course of a human disease.28
History of Disparity in Medical Education
Box 1 chronicles the remarkable history of the education of women physicians and physicians of color in a nation that for more than a century made no formal provision for the education of nonwhites and then chose to relegate them to segregated schools with inferior textbooks and equipment. Not only were African Americans pioneers in the advancement of their own education, but their contribution to advancement in many fields of medicine is also significant. Several suggested readings and links are listed at the end of this chapter for readers who wish to learn more.
Despite the progress that has been made, barriers and biases continue to impede the progress of those underrepresented in medicine (URM) and women who choose to enter the field of medicine. An important study in the Journal of the National Medical Association reported that women believed that the specialties they were encouraged to pursue were affected by their gender and that they were often mistaken for nonphysicians. URM students noted that a lack of same-race role models had a negative impact on their medical school experience, and they overwhelmingly reported feeling the need to be “twice as good” to be treated as equal to white students.29
Diversity and Cultural Competency
Definitions
The definition of some important terms, broadly and more specifically as they relate to EM, will help provide a common understanding and language for the reader. According to the Webster dictionary, culture is defined as “the customary beliefs, social forms, and material traits of a racial, religious, or social group; also: the characteristic features of everyday existence shared by people in a place.…”24 When individuals from the general population come into contact with the health care system, they bring with them their culture and all that it encompasses: their beliefs, values, identity, and links to the community.
According to the IOM report in 2003, the committee defined disparities as “racial or ethnic differences in the quality of healthcare that are not due to access-related factors or clinical needs, preferences, and appropriateness of intervention.”30
When people from different cultures and backgrounds come together, diversity is achieved. As defined by the Merriam-Webster dictionary, diversity is the “inclusion of different types of people in a group or organization.” According to the 2010 U.S. census, there are currently more than 300 million Americans: 65.1% white, 15.8% Hispanic, 12.9% black, 4.6% Asian, and 1.2% American Indian or Alaskan Native.31 Recognizing how the changing patient demographics in the United States should be reflected in the physician workforce, the Association of American Medical Colleges (AAMC) Executive Council in 2003 adopted a definition of URM as “those racial and ethnic populations that are under-represented in the medical profession relative to their numbers in the general population.” Before this, the AAMC used the term “under-represented minority,” which specifically targeted African Americans, Mexican Americans, Native Americans, and mainland Puerto Ricans. A much broader definition of diversity includes racial and ethnic, socioeconomic, sexual orientation, religion, disability, age, language, and geographic diversity.6
The Office of Minority Health (OMH) defines cultural and linguistic competence as “a set of congruent behaviors, attitudes and policies that come together in a system, agency or among professionals that enables effective work in cross-cultural situations.”32
Tools for Cultural Competency
The educational concepts for cultural competency are centered around the provider gaining the knowledge, attitude, and skills necessary to elicit patients’ explanatory model of their illness and incorporating it into the medical decision-making process. The skills that lead to this competence are not so different from those that we envision when we think of the ideal humane, compassionate, and caring physician. In the end, this concept helps create a framework that allows the health care provider, with a general approach to any patient from any cultural background, to navigate the cross-cultural experience. In effect, this leads to greater understanding of the patient’s perspective and social context. An important conceptual model recently published by the Agency for Healthcare Research and Quality titled “Can Culture Competency Reduce Racial and Ethnic Health Disparities? A Review and Conceptual Model” describes how integrating nine major cultural competency techniques could potentially improve the ability of physicians and health care systems to deliver appropriate services to diverse populations33:
