At MNT, we have zoomed in on some of the inequalities in healthcare that COVID-19 has exposed by interviewing experts and looking at the evidence available.
We looked at the disproportionate effect that COVID-19 is having on black communities in the United States, the public health impact of police violence, and the impact that incarceration may have on the new coronavirus spread, to name a few of the issues in the spotlight.
But COVID-19 has only served to exacerbate inequalities that were already present before the pandemic started.
In this Special Feature, we examine health inequities more broadly and the way they are impacting people of color in the U.S.
Specifically, we are sharing with our readers what MNT’s experts want them to know about these issues.
Dr. Angela Bell, double board certified in internal medicine and sports medicine, spoke to MNT about what health inequities mean, and how she perceives them through her medical practice.
“My patient population is mostly African American, and this population suffers from health inequities. Health inequities are differences in healthcare and health outcomes that occur because of race/ethnicity, socioeconomic status, age, location, gender, disability status, or sexual orientation.”
“The risk for health inequities,” she explained, “is compounded with suboptimal ‘social determinants of health.’ People with lower education, lower income, smaller support systems, less access to quality care, and quality foods experience poorer health outcomes.”
Wealth and income, specifically, play a key role. In the relationship between income and health, COVID-19 has made it apparent that disparities in the former lead to disparities in the latter.
Debra Rose Wilson, RN, Ph.D., associate professor in the Nursing School at Tennessee State University in Nashville, explained for MNT that, in turn, health inequities further deepen the income disparities, leading to a vicious circle. “Health inequities cost everyone financially,” she said.
“People trapped in inequities cannot change their situation easily. For example, the poor are at higher risk for obesity, not because they eat too much or are lazy, but because they cannot afford high quality health[ful] foods to prepare for their family. It is less expensive to feed their family foods [that] contribute to obesity.”
– Debra Rose Wilson, RN, Ph.D.
“Those who are poor cannot exercise easily because their neighborhoods may not be safe for walking, and a gym membership is not achievable. The poor don’t have access to community education programs, such as cooking or yoga classes. The costs of obesity end up as costs of healthcare that have to [be] paid.”
“Programs [that] target health inequities to help develop education, health[ful] food access, and family support help reduce the disparity,” added Wilson.
Research that MNT reported has shown that “Across virtually every type of therapeutic intervention in the U.S., ranging from high technology procedures to the most basic forms of diagnostic and treatment interventions, [Black people] and other minorities receive fewer procedures and poorer quality medical care than [white people].”
This disparity is largely due to a wide variety of biases and stereotypes in healthcare.
Femi Aremu, PharmD, Medical Integrity Pharmacist at Healthline Media, explained for MNT:
“Black people in America are often perceived by healthcare professionals to be lying about physical pain. This bias can cause Black people not to seek medical attention when necessary and increase misdiagnoses. Believe Black people.”
– Femi Aremu, PharmD
Dr. Valinda Riggins Nwadike, MPH, echoes a similar idea and also expressed the sentiment that all too often, healthcare professionals do not believe or hear Black people.
As a result, there is a growing mistrust of healthcare professionals among African Americans, which has negative consequences in itself, further deepening the disparities and reserving quality care for some only.
“As an African American health care provider, my patients remind me of my relatives,” said Dr. Nwadike.
“Many are distrustful of the healthcare system and often don’t feel they get the attention they deserve, and many don’t. Keep in mind minority patients need to feel heard and validated.”
Prof. Tiffany Green had made a similar point in the interview she gave MNT, speaking about the consequences it has for COVID-19.
She said: “Academic medical centers, universities, public health departments […] have unfortunately earned the mistrust of many of the communities they purport to serve.”
“Thus, failing to consider these issues means that contact tracing will not be as effective in communities of color,” Prof. Green warned.
Medical experiments and bias lead to lack of trust
Dr. Angela Bell also spoke to MNT about the mistrust in medical institutions and about what doctors can do to meet their patients halfway.
She said: “As a physician, I try to focus on the part of the equation that I can positively affect, quality of care and health education. It is important for physicians to know that there is a long history of mistrust between African American patients and the healthcare system that stems from years of racism.”
“For example, the Tuskegee experiment was conducted on African American men with syphilis from 1932–1972. They were studied to evaluate untreated syphilis without their knowledge, and they were not given penicillin even when this became the mainstay of treatment in 1947.”
“It is also important for physicians to understand implicit bias. A recent study showed that white medical students believed that Black patients had thicker skin and less sensitive nerve endings. These biases lead to real consequences. African American patients are less likely to receive pain medications than other races, for example.”
“These experiences lead to mistrust, which leads to patients not seeking out preventive care or treatment for medical conditions that they have. Physicians must have the knowledge of this history and take this into account when treating African American patients and work to nullify their implicit biases and build trust, so together, optimum health can be achieved.”
– Dr. Angela Bell
Dr. Bell continued, “Patients who have received poor quality care must be empowered to be their own advocate and seek out a physician who will give them the quality care they deserve, so together optimum health can be achieved.”
Femi Aremu also commented on institutional racism and its consequences on healthcare inequalities.
“The medical industry and the research behind it is a reflection of the white dominant culture,” he said.
“Until institutions begin to care and research the diversity of bodies, there will always be inequities in the healthcare system.”
As an example, the MNT expert focused on the notion that Black Americans are hit harder by the pandemic because they are more likely to have comorbidities — an idea expressed by Alex Azar, secretary of the Department of Health and Human Services, among others.
“I’m tired of people blaming the disproportionate number of Black people dying from COVID-19 on high blood pressure and diabetes,” said Aremu.
“Let’s talk about who has access to health insurance, or who can’t work from home because they are in the service industry, or who is incarcerated [at] a higher rate due to racism. Environmental racism is a well-oiled machine.”
– Femi Aremu, PharmD
Black women in the United States are also subject to biases that end up affecting their sexual and reproductive health.
“According to the CDC [Centers for Disease Control and Prevention] and U.S. census,” continued Aremu, “Black women are three to four [more] times more likely to die during childbirth in the U.S. [given that] Black people make up less than 14% of the total population. Believe Black women.”
Dr. Amanda Kallen, who has expertise in the field of reproductive health, also shared her experience with MNT.
“Because I am a reproductive endocrinologist and infertility specialist, a lot of my time is spent with individuals and couples trying to grow their family,” she said. “So, this is where my particular interest lies.”
“There are so many stigmas around fertility and women of color — for example, that Black women don’t have problems with fertility. This can make it hard for a woman to talk about her struggles with infertility, let alone seek treatment.”
“We, as medical providers, must do better. We must acknowledge systemic racial bias in medicine. We must improve pregnancy outcomes for women of color. We must ensure that fertility treatment advertising is inclusive. And we must begin to have loud conversations about infertility among women of color and work to erase the myths that are out there.”
– Dr. Amanda Kallen
The noxious effects of systematic racism in healthcare do not stop at reproductive health for women.
Dr. Catherine Hannan, MPH, a plastic surgery specialist, spoke to MNT about the impact on reconstructive surgery, particularly for females having a mastectomy after breast cancer.
“In light of the #blacklivesmatter movement, I’d like to emphasize one point that is particular to my field of plastic surgery,” Dr. Hannan said.
“In 1998, Congress passed the Women’s Health and Cancer Rights Act (WHCRA), which requires most group insurance plans that cover mastectomies to cover breast reconstruction. Still, 20 years later, only half of all women requiring a mastectomy are currently offered breast reconstruction surgery.”
“In fact, one in five women who do not undergo breast reconstruction reported a lack of knowledge about the procedure. Of those patients not getting reconstruction, most studies found that women of color were less likely to receive postmastectomy breast reconstruction compared to white women. System associated factors, physician associated factors, and patient associated factors interact in a complex manner that contributes to the reported disparities.”
“In light of these disparities,” Dr. Hannan continued, “in 2015, Congress passed the Breast Cancer Education Act, to ‘educate breast cancer patients anticipating surgery, especially patients who are members of racial and ethnic minority groups, regarding the availability and coverage of breast reconstruction and other options.’”
“While the gap is closing, we still have much work to do to end the pervasive systemic racism plaguing our healthcare systems and ensure that our patients of color receive the same treatments and, ultimately, outcomes, as white patients.”
– Dr. Catherine Hannan, MPH
