The Henry J. Kaiser Family Foundation
At the Heart of Race and Health Care
11/27/00
By Linda Wright Moore Reprinted with permission of Philadelphia Daily News
Dr. Charles Bridges, assistant professor of surgery at Penn’s medical school and clinical director of cardiac surgery at Pennsylvania Hospital, understands that racial disparities in health care are much more than skin deep.
That premise is clear in his latest research, a study of differences in the death rates of blacks and whites who undergo coronary bypass surgery. His study was published last week in the Journal of the American College of Cardiology.
Bridges and his colleagues found that fewer than 4 percent of all patients studied died as result of coronary artery bypass surgery – but that black patients were 29 percent more likely to die than whites. And that’s even when other known risk factors, such as age, kidney failure and heart failure, were taken into account.
So what’s going on?
“Race is probably a marker for other biological variables that may have to do with cell function that protects people from heart disease,” Bridges hypothesized.
“These cells may work differently in some black patients, so that they tend to have less protection and more severe heart disease at an earlier age. . .So blacks may have higher mortality, not because they are black, but because of a different biology.”
That biological difference might be shared by some black people – and by people of other races as well.
But to sort it all out will require more research.
Expensive, extensive research. And on Wednesday President Clinton signed into law a measure that could help fund research like Charles Bridges’.
The new law could be a foundation and a first step toward eliminating wide and persistent health disparities that cause millions of Americans to live sicker and die sooner than most of their fellow citizens.
First introduced in June 1999 by U.S. Rep. Jesse L. Jackson Jr., D-Ill., the legislation that became the Minority Health and Health Disparities Research and Education Act of 2000 was strongly supported by Democrats. But the proposal was almost derailed when conservative House Republicans circulated a memo claiming the bill contained “several racial set-asides and quotas” for grant and loan programs.
The bill was rescued by Republican Sen. Bill Frist, who represents a Tennessee constituency of low-income blacks and Appalachian whites. Frist expanded the bill to include all health disparities – including those experienced by poor whites.
Now, the new law calls for:
Annual spending of at least $100 million for research on health disparities.
$50 million for studies to identify causes of health disparities and explore strategies for eliminating them.
$21 million for education programs to help doctors learn techniques of “culturally competent” care.
Unspecified funding for repayment of educational loans to health professionals who conduct research on minority health or health disparities.
Add in the budget of the existing Office of Research on Minority Health and the total for research into how race affects health is nearly $250 million per year.
“To address this problem with a more targeted approach, we need better data and understanding of the factors that drive the problem,” said Marsha Lillie-Blanton, an African-American who is vice president of the Kaiser Family Health Foundation, where she directs policy research and grants on access to care for vulnerable populations.
“In the past, most researchers studying us were not people who understand us and our communities. This [new law] will train minority researchers and invest in research targeting the needs and problems of minority and disadvantaged communities.”
Money and a solid hypothesis drive research. Along with new dollars under the minority health and disparities law, the nonprofit Center for the Advancement of Health recently announced a $1.5 million pilot program funded by the W.K. Kellogg Foundation, “to train a new generation of minority scientists” to research and solve disparities in health care.
These new resources will enable scientists like Charles Bridges to expand their research.
“We need to systematically investigate biological differences that we found in black patients, such as more severe heart disease at a younger age,” Bridges said. “We also need long-term studies. What about one-year or five-year or 10-year mortality? That would take years, and it would be expensive.”
Expensive and complicated – because, even if race is a factor in medical outcomes, it’s not in itself an answer to the question of eliminating racial disparities in health. “We cannot treat race, but we can treat biological factors,” Bridges pointed out.
So it becomes essential to figure out how biology, poverty, access and culture apply to minority health by asking an array of questions that have clinical and social implications.
“We need to look at the influence of socioeconomic variables,” Bridges said. “Are blacks getting service from the same surgeons as everyone else, or does a certain, limited group of surgeons treat blacks? Are there differences that correlate to where blacks live and the quality of care available in their communities?”
The only downside to the creation of a center devoted to minority health is the risk of “ghetto-izing” research on minorities into a niche with minimal funding, Lillie-Blanton said. The $250 million authorized to begin studying minority health and health disparities is just 1.4 percent of annual National Institute of Health spending.
“It’s not the answer, but it provides an opportunity we haven’t had before to develop research by people who are more knowledgable about our community,” said Lillie-Blanton. “It’s information that will help to leverage what kinds of research should be done in the other divisions of NIH, with larger sums of money.”
The other big problem underlying the issue of health disparities is access – the problem of being less likely to be referred for bypass surgery, heart transplants, angioplasty or catheterization.
“We need to educate physicians and patients about the benefits of these interventions,” said Bridges, “especially where there is no economic barrier to paying for the procedure.”
Bridges said often poor communication between doctor and patient results in less aggressive care for some minority patients, but attitudes about race are also a factor. “We cannot deny that there is a difference in physician attitudes that gets manifest as patient access,” Bridges said. “I have had several African-American patients who, prior to meeting me, had declined to have surgery.
“When I was able to communicate to them the risks, benefits and alternatives in a manner which they found clearer, less threatening and more sensitive to their views, in several cases they agreed to undergo procedures that were necessary.”
One component of the new law specifically calls for education efforts in “culturally competent” care, to help doctors – who are primarily white and male – learn to more effectively treat patients who will be, increasingly, non-white as the nation’s demographics shift in the 21st century.
Along with money, research takes time. And so does changing the way patients are treated. For now, according to Bridges, the best way to reduce race-based disparities in health is for patients and doctors to decide on the appropriateness of heart surgery and other cardiac treatments based on “established clinical data, independent of race.”
Dr. Thomas LaVeist, a professor and researcher at the Johns Hopkins School of Public Health, is also studying the touchy issue of why whites and blacks get different treatment for cardiac problems.
“The new resources that will flow from the center for minority health are important for researchers who have been toiling for years in the area of disparities in health, and haven’t been able to get the support they need,” LaVeist said.
“Although the center itself has a relatively modest budget now, hopefully, that budget will grow.”
