Keziah Babu, Selma Hot, Warveen Othman, Fawzia Shirzad, Zuzanna Niewiadomska
Throughout history, health disparities have plagued minority groups across the nation. The infamous “Tuskegee Study of Untreated Syphilis in the Negro Male” of 1932, conducted on 600 African American men without their consent, is a major component of the much larger discussion on healthcare disparities based on race and socioeconomic status. In the Tuskegee Study, the goal was to observe the effects of untreated syphilis. However, the subjects of the experiment were deceived into thinking that the researchers were treating them for any conditions they had. Even when penicillin was proven to be the treatment of choice for syphilis, the test subjects were not treated, and the study continued (Centers for Disease Control and Prevention, 2021). Due to the color of their skin and their status in society, the researchers of the study deemed them unworthy of receiving the proper health care that would have been readily provided to a White person.
The disparities that were present years ago continue to permeate the modern-day health care system. Marginalized groups, such as African Americans and Hispanics, continue to face higher morbidity and mortality rates, despite the cause of death. Despite government initiatives that have been implemented to counteract healthcare disparities against minorities, minority communities continue to be affected by illness in larger proportions compared to White communities (Giger, 2007). An imperative aspect of ethical medicine is to treat the sick, regardless of their cultural background, religion, gender, or socioeconomic status. In this paper, we will focus on health disparities experienced by the African American and Hispanic populations, how the COVID-19 pandemic highlighted pre-existing healthcare disparities within the U.S., and how the PA profession can address and improve upon this critical issue.
There are approximately 60.5 million Hispanics currently living in the United States, making them 18.4 percent of the entire U.S. population (Bustamante, et al, 2020). Unfortunately, Hispanics are reported to have the highest uninsured rates amongst all races (Office of Minority Group, 2021). Additionally, many experience barriers to good health due to differences in language, cultural norms, inadequate access to preventative medicine and care due to the lack of health insurance. In addition, many Hispanics are undocumented, have undocumented employment, have low-paying jobs, and little knowledge about the U.S healthcare system, all of which make access to quality healthcare a challenge.
As reported by the Human Health Services, although Hispanics have a lower incidence of hepatitis C, they are 40 percent more likely to die from it than non-Hispanic Whites (Office of Minority Group, 2021). Most patients are not aware of the implications of not understanding their health state, being regularly screened, or immunized against this disease. It is the responsibility of the clinician to make every attempt at ensuring that patients are thoroughly informed. Without this, we disrupt the ethical concept of distributive justice, where health care should be equitably distributed amongst all patients regardless of skin color, socioeconomic status, or ethnicity. Clinicians have an obligation to provide services in a just and fair design.
A crucial aspect that must be considered as a significant barrier to healthcare access is limited English proficiency along with cultural differences. According to a study by Cigna health insurance company, approximately one in three Hispanics is not fluent in English (White Paper, 2016). When interpreters are incorporated, cultural differences are considered. We as a nation fail to grasp their individuality and understand that every person is unique and has different life circumstances, expectations, challenges, and needs. Whether apparent or not, clinician viewpoints are sometimes biased, stereotypical, or prejudiced. To avoid such viewpoints, cultural competency allows providers to gain insight into the patient’s cultural norms, their barriers to health care, and can better recognize when an interpreter is needed. It is essential that all hospital staff engage in cultural competency training as many clinicians are involved in a patient’s care (Heath, 2020). In doing so, the patient-provider relationship is strengthened leading to the delivery of quality of care, patient satisfaction, and increased adherence to treatment regimen.
A discussion on health disparities in the United States would be greatly lacking if it neglected to mention the immense social injustice towards black Americans. While healthcare providers in this country have been trained for many years to provide ethical and unbiased care, especially in the context of race, current research still demonstrates an inexcusable trend of African Americans receiving care that is of significantly poorer quality relative to other populations. An article published by Public Health Reviews in 2016 highlighted several of these health inequalities, which further illustrate why this is still a discussion in current healthcare practice and ethics (Noonan et al., 2016).
Although the gap in life expectancy has decreased over time, Black Americans still live shorter lives on average when compared to White Americans. The rate of premature death is also higher in Blacks compared to Whites. On a more specific note, racial inequities are seen very clearly in prenatal care and neonatal mortalities. Only about a decade ago, Black infant mortality rates were about double that of White infants. In 2014, the rate of low birth weights and preterm deliveries were highest among Black women. In addition, not only did fewer Black women get prenatal care compared to White women, but they also reported receiving less prenatal care advice regarding subjects such as smoking cessation, breastfeeding, and alcohol use. Racial implicit bias from the provider aspect could very well be a major factor in causing this injustice. In addition, a 2014 report from the American Heart Association noted that Black citizens had a “1.3-times greater rate of non-fatal stroke, a 1.8-times greater rate of fatal stroke, a 1.5-times greater rate of death attributable to heart disease, and a 4.2-times greater rate of end-stage kidney disease.” When looking at cancer as a whole, Black people had the highest incidence and death rate in 2012. Unfortunately, the list goes on. These are only a few examples of the health disparities seen in African Americans which are primarily tied to the color of one’s skin (Noonan et al., 2016). In the ethical context, the importance of fairness must be evaluated here among several topics. A “fair” medical system would provide all patients with equitable healthcare that they deserve and can reasonably expect. The statistics discussed make it evident that healthcare in the US is not only inequitable, but they also suggest that the system deprives deserving populations from quality care based on their race, which is unquestionably unethical.
The COVID-19 pandemic brought social and racial injustice to the forefront of public health, highlighting that health care disparity remains an unfortunate reality and continues to put racial and ethnic minorities at increased risk. According to an analysis provided by the Kaiser Family Foundation and Epic Health Research Network, the COVID related hospitalization rates and death rates per 10,000 as of July 2020, were respectively, 24.6 and 5.6 for Black patients, 30.4 and 5.6 for Hispanic patients, 15.9 and 4.3 for Asian patients, and 7.4 and 2.3 for White patients (Lopez et al., 2021). It is essential to account for these differences in COVID-19 outcome, of which, social determinants of health is the largest contributor, and continues to prevent these groups from seeking health equity.
In the U.S., marginalized groups have lower socioeconomic status, but the disparities in socioeconomic conditions across racial lines have been exacerbated by the pandemic. Blacks, Hispanics and American Indians are more likely to live in crowded conditions, have jobs which are considered essential and cannot be performed remotely such as transit workers, grocery store clerks, etc., and are more likely to travel on public transport – all of which increase likelihood of exposure to the SARS-CoV-2 infection. Moreover, racial and ethnic minority populations have poorer access to health care, which likely results in persons initiating care later in the course of their illness with COVID-19 (Lopez et al., 2021). All of these challenges have detrimental effects on downstream health outcomes.
While it may seem peculiar that the United States, one of the world’s wealthiest countries, was so ill-prepared and susceptible to the spread of COVID-19, it is clear that our lack of an adequate public health infrastructure played a large role in the greater spread. While we attempt to reform our health care system, we must consider that 70% of variation in health outcomes is tied to social determinants rather than the health care that one receives (Wen and Sadeghi, 2020). So, while ensuring minority communities are receiving equitable access to testing, treatment, and vaccinations is an important step, it is not enough because of the multifactorial contributions that create barriers to health care, even if access is increased. One of these attributes is limited health literacy among minorities. This concern was highlighted in a study that found Black men (n = 830) were less likely than White men (n = 3759) to have health-related knowledge about the symptoms and the mechanisms to spread COVID-19 (Lopez et al., 2021). This suggests that public health information is not disseminated in ways that are equally understandable to vulnerable populations and underscores the need to allocate resources to mitigate this disparity.
Addressing health disparities is one area the PA profession can step in and make a big difference. Based on the Guidelines for Ethical Conduct, PAs are professionally and ethically committed to providing non discriminatory care to all patients. Therefore, it is crucial for PAs to take action and help mitigate health inequities in clinical practice.
One way this can be achieved is by teaching PA students about implicit bias during the didactic phase of education. Implicit bias is an unconscious bias such as an attitude, belief or stereotype that is automatically activated, affecting our unconscious thoughts and actions in a positive or negative way (Buchs & Mulitalo, 2016). PA educators can make students aware of their implicit bias by having students take an Implicit Association Test (IAT), such as the Harvard IAT, and discuss the role of implicit bias in creating health disparities in clinical practice. Buchs (2016) states it is important to formally educate PA students on implicit bias because it is at the unconscious level.
As discussed, cultural competency training can help mitigate health disparities experienced by the Hispanic culture and any other minority group. Therefore, cultural competency training should also be included in the PA curriculum to increase student awareness of various culture norms, explore barriers to health care and facilitate intercultural communication. PA students need to be aware of social determinants of health and how they can mitigate health disparities on an individual level by asking clarifying questions.
Perspective-taking exercises, where students strive to take on another person’s thinking and feeling, is another tool that can be used in PA education. Researchers have demonstrated that perspective-taking exercises increase empathy, facilitate altruism, improve communication and decrease stereotyping and prejudice (Blatt & Mulitalo, 2010). Empathy can facilitate healthy equity because a clinician’s empathy plays an important role in building a good patient-provider relationship which can improve health outcomes and patient satisfaction. Three randomized controlled studies by Blatt et al. (2010), showed that student-clinicians given the perspective-intervention received significantly better patient satisfaction scores from standardized patients than did controls.
Health disparities can also be countered through interventions targeted towards practicing PA clinicians. Analysis of Outside the Box CME completed by PAs between 2017 and 2019 showed that PAs significantly improved across all five domains known to influence health disparities (Zuber et al., 2020). The domains addressed were sexual orientation and gender identity, race and ethnicity, literacy, physical, cognitive and sensory disability and economic or logistic insecurity. In post-interventional data collected, participants stated that asking more questions of patients elicited more information that changed the direction of care, differential diagnoses became more inclusive and there was an increase in medication compliance. This study demonstrates that provider behavior can be changed through targeted quality improvement interventions which increase a provider’s awareness of their shortcomings and provide education on ideal behaviors.
PA education and targeted interventions are important in helping mitigate health disparities and advancing health equity. The COVID pandemic further increased public awareness of racial and distributive injustice as it “sickened, hospitalized, and killed people of color at higher rates than White people because of many factors, including an increased risk of exposure, unequal access to testing and high-quality care, higher rates of medical conditions associated with poor outcomes, and less access to vaccination” (Lavizzo-Mourey, Besser, & Williams, 2021). It is therefore imperative that PA students and practicing clinicians continue to actively reflect on their implicit biases and seek out opportunities that help break down barriers that result in health disparities. Based on the ethical principle of justice, no patient should receive a lower standard of care based on their race, age, sex, culture, socioeconomic status or religious beliefs.
References:
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