Much of the problem with racial disparity in healthcare stems from the "culture of medicine," Prof. Carolyn Rouse declared during the fourteenth program in the Division of United States Studies' New Scholarship in Race and Ethnicity series. The phrase, coined by commentator Mary-Jo DelVecchio Good, refers to the training doctors receive that teaches them to rely more on standard treatments and diagnoses than on a patient's unique needs.
Rouse used the example of sickle cell disease as indicating the factors that affect doctors' treatment of patients. Basing their diagnoses on what the statistics say about sickle cell disease, doctors may both ignore the way the statistics are put together and what they see as the patients' unreliably subjective reports of severe pain. Sickle cell patients complain that the severe pain that frequently accompanies the disease is often ignored or under-treated.
That has a great deal to do with racial signifiers, Rouse asserted, as such signifiers "affect the scope of patient access." Sickle cell disease affects African Americans disproportionately and is frequently found among poorer patients, whom many doctors assume are either less intelligent or less willing to follow the kind of lifestyle that might alleviate their symptoms, and whose physical ailments they may therefore be disposed to treat with less care. The patients, many of whom also lack health insurance, are therefore dependent on the compassion of physicians. That compassion is hard to find, as all three panel participants agreed, both because of what may be unconscious racism and because of the pressure that managed health care puts on today's doctors to treat patients as infrequently and as quickly as they can.
Some medical personnel and social workers have responded to the problem by training sickle cell patients to "act like more acceptable citizens," speaking to doctors in language to which they can relate more easily and, in effect, seeking to "change the patients in order to end social injustice." Rejecting that solution, Rouse argued that "health care needs to be a matter of right" and that racial disparities in health care will not end until there is a universal health care system. Such a system, she asserted, is essential to reducing the overall costs of health care, which would in turn improve the overall health of the nation.
Agreeing that the healthcare system is not working, particularly for minority racial and ethnic groups, Dr. M. Gregg Bloche and Prof. Good emphasized that the most important cause of the differential in treatment has to do with the possession or lack of insurance. In fact, Bloche said, income – which is frequently tied to health insurance – and environment affect health far more than does medical care. The "pervasive reality of subjectivity and discretion in medical practice," including each doctor's interpretation of what a patient reports and of the results of physical examinations, along with his or her choice of the plethora of possible treatments that exist for many physical conditions, give free play to unconscious racism and classism. Good added that the issue of trust is central. Patients are less trusting of doctors than they once were, perhaps because they sense that physicians in turn trust what they are taught rather than patients' narratives.
Unfortunately, current trends in the healthcare system, Bloche warned, will result in greater disparities in health care. We are now moving from a post-managed care system toward consumer-directed health care which, by increasing deductibles and consumer cost-sharing, will marginalize the health care available to poorer citizens all the more. The way to achieve more equitable healthcare, Bloche argued, is to provide generous, well-tailored subsidies to both private and public health care systems. As Rouse concluded, with less emphasis on costs, doctors would be able to place their focus where it belongs: on the treatments that will produce better health outcomes for all their patients.
Drafted by Acacia Reed and Philippa Strum
Philippa Strum, Director of U.S. Studies 202-691-4129