HEALTH EQUITY, IS IT REALLY ACHIEVABLE?

As a student in medical school I have a host of memories that I believe would still remain vivid in my mind for ages. One such image is my experience as a 4th year medical student observing an amputation. The consultant orthopedic surgeon gave us a brief history of the patient. The patient was a 51 yr old local chief who he had seen 2 years ago for a painful swollen leg, initial evaluation suggested that this man had a bone cancer of his leg bones below the knee ( osteosarcoma of the tibia bone). At the initial visit he recommended amputation for the gentleman but the patient declined amputation and decided to seek a second opinion from an alternative medical practitioner ( in this case most likely herbal healers or a spiritualist). It was obvious he did not get any good assistance from these practitioners because he still ended up in the operating room after 2 years. By the time I saw him that day his whole left leg was wrapped in bandages up to the thigh and the room already had a putrid stench from the decaying tissue from his cancer. In that OR it was a relief when the amputation was done and the amputated limb with decaying flesh was taken out of the OR.  The question that we all asked was, how was he able to live with that limb for that long?  None of us knew the exact answer to this question but knowing this gentleman’s heritage and lineage did give us some insight into why he kept a painful decaying and outright smelly leg for close to two years before agreeing to go ahead with an amputation. Our patient was a chief whose ethnic group in Ghana believe that a chief must be whole. Even though most men in his ethnic group are circumcised as a matter of custom those of royal lineage do not get circumcised. An amputation for him was equivalent to abdicating his stool, when he came in initially his stool was more important than his health, with time though his health became more important.

In the United States today, health disparities comparing non-hispanic whites to African Americans is a problem that has mostly eluded good solutions because of the complexities involved. Overall though most researchers agree that the differences in health outcomes seen among whites and African Americans goes beyond genetics and environmental and societal issues are the major determinants. The IOM (Institute of Medicine) Report ‘Unequal Treatment’ released in March 2002 did highlight some of the underlying issues creating these disparities.  Access to adequate healthcare due to lack of insurance and a the resulting tendency for most low income minority patients to seek care later in the course of their diseases is one important determinant. Another issues which is sometimes not well appreciated is the impact of implicit racial bias on the health care that minorities receive.  Humans over time have developed ways of quickly assessing and judging their environments, this is an intrinsic part of our upbringing. Professionals in all fields including defense, medicine, air traffic safety etc use similar system of learned associations to make quick decisions in various situations.  These associations that enable quick ‘effective’ decision making whilst usually very useful, may also make us prone to implicit bias.

In the area of healthcare this can adversely affect the outcomes of certain members of racial and ethnic minority groups if our learned associations do not apply to them. In cases in which we have some understanding of the culture of these minorities we can easily spot these and address the situation.  One solution that most policy makers support is to increase the number of minority providers in healthcare. Whilst increased minorities in healthcare may be a solution we must all be aware that implicit bias usually transcends race and is usually a feature of the dominant culture transmitted to most key actors in most fields. Minority providers trained in the dominant culture acquire some of the biases as a result of their training.

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To adequately address some of the determinant of disparities all providers must learn to understand their biases and modulate their actions to help reduce the impact of these biases on patient outcomes.  Providers and health systems must understand that some of our patients may need to be managed differently to achieve good outcomes. Most important of all though our state and federal legislators must understand that until we can make decent healthcare easily accessible to all irrespective of race, educational and socioeconomic status all our efforts research and reports would only remain reports.

By Dr. Leonard Sowah, an internal medicine physician in Baltimore, Maryland 

 

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