Perspective: Barriers to Eliminating Disparities in Clinical Practice – Lessons from the IOM Report “Unequal Treatment”

Abstract

Over the last 200 years, the USA has experienced dramatic improvements in overall health and life expectancy largely due to initiatives in public health, health promotion, and disease prevention. Nevertheless, despite interventions that have improved the overall health of the majority of Americans, racial and ethnic minorities have benefited significantly less from these advances. National data indicates that minority Americans have poorer health outcomes (compared to whites) from preventable and treatable conditions such as cardiovascular disease, diabetes, asthma, cancer, and HIV/AIDS, among others (The 2008 National Health Care Disparities Report. Rockville: Agency for Health Care Research and Quality, 2009; Eliminating Racial and Ethnic Disparities in Health. Prepared by co-sponsors Grantmakers in Health for the DHHS conference: “Call to Action: Eliminating Racial and Ethnic Disparities in Health.” Potomac, MD, 11 Sept 1998). Multiple factors contribute to these “racial and ethnic disparities in health.” First and foremost, research has demonstrated that social determinants such as lower levels of education, overall lower socioeconomic status, inadequate and unsafe housing, racism, and living in proximity to environmental hazards disproportionately impact minority populations and thus contribute to their poorer health outcomes (Williams, Soc Psych 53:81–89, 1990; Pincus et al., Ann Intern Med 129(5):406–411, 1998; Hinkle et al., Science 161(838):238–246, 1968; Antonovsky, J Chronic Dis 21(2):65–106, 1968; Pincus and Callahan, Advances 11:4–36, 1995). One poignant example of the impact of social determinants is the fact that three of the five largest landfills in the country are in African American and Latino communities, thus contributing to some of the highest rates of pediatric asthma among these populations (Flores et al., JAMA 288(1):82–90, 2002). Second, lack of access to care also takes a significant toll, as uninsured individuals are less likely to have a regular source of care, are more likely to report delaying seeking care, and are more likely to report that they have not received needed care – all resulting in avoidable hospitalizations, emergency hospital care, and adverse health outcomes (Andrulis, Ann Intern Med 129(5):412–416, 1998; Health care Rx: access for all. Barriers to health care for racial and ethnic minorities: access, Workforce diversity and cultural competence. Boston, MA: Department of Health and Human Services and The Health Resources and Services Administration, July, 1998; No health insurance? It’s enough to make you sick. Philadelphia, PA: American College of Physicians-American Society of Internal Medicine (ACP-ASIM), 2000). This is especially important for minority populations who are more likely to be uninsured than their white counterparts. Data from the US Census Bureau demonstrating that between 2004 and 2006, 33% of Hispanics, 31% of American Indians and Alaska Native, and 19% of African Americans were uninsured, compared to only 15% of whites (DeNavas-Walt et al., Income, poverty, and health insurance coverage in the United States: 2006. Washington, DC: U.S. Census Bureau, U.S. Government Printing Office, 2007).

J.R. Betancourt

Director, The Disparities Solutions Center, Senior Scientist, The Institute for Health Policy, Director of Multicultural Education, Massachusetts General Hospital, Associate Professor of Medicine, Harvard Medical School, Boston, Massachusetts, USA