The Boston Globe, December
05, 2010
Women
and minorities have been overlooked by the Health system, but
what can we do?
It's one of the biggest
problems facing the US health care system: Women and minorities
are treated differently than white men. There are wide disparities
in everything from nutrition to insurance to testing to treatment.
The Globe recently asked local doctors about the health issues
facing women and minorities and what can be done to narrow the
health care gap.
Participants in the
discussion included Dr. Paula Johnson, chief of the division of
women's health at Brigham and Women's Hospital in Boston; Dr.
Alice Tolbert Coombs, president of the Massachusetts Medical Society;
and Dr. Joseph Betancourt, director of multicultural education
at Massachusetts General Hospital. Diversity Boston editor Kortney
Stringer conducted the interview at the Globe, and what follows
are edited excerpts from the discussion:
Globe: What are some
of the biggest health issues facing minorities?
Betancourt: An issue
that we all have to work on is this issue of disparities in health
care, differences in quality of care stratified by race or ethnicity.
Even when minorities have the same socioeconomic status or education
or insurance, they still receive a different quality of care.
Coombs: You have to
distinguish between health disparities and what is a difference
in treatment regardless of what the . . . cause of that difference
in treatment is. When you talk about health disparities, I think
of a list of things like obesity, cardiovascular disease, diabetes,
hypertension. You have to pay close attention to the socioeconomic
impact of where the person lives, where they reside, and what
their income status is, their education level.
And then if you were
to take the other bucket of health care disparities, it would
include when someone actually comes in contact with the health
care delivery system. What happens to them? Are they treated the
same?
Johnson: Frequently,
the propensity might be to try to address issues of health and
health care disparities in one bucket. For example, if you were
to look at type 2 diabetes or adult onset, it's no longer adult
onset because there are a lot of kids who are getting it unfortunately,
which for example, has a higher rate in black and Latino populations.
Women, in particular, have higher rates of diabetes.
You can look at some
of the environmental factors. You can look at issues around obesity.
You can look at issues in terms of outcomes with regard to health
care delivery. But there are other aspects of disease that we
don't fully understand - what are some of the genetic predictors
that aren't necessarily unique to racial groups because race isn't
genetic? There is a science that we need to more fully explore,
and it's true not only in diabetes, but for example, in breast
cancer, where black women tend to come in with more aggressive
cancer. Why is that true? There are issues of access to care,
but there are also biologic differences that we have yet to fully
uncover.
Globe: What are the
biggest issues in women's health?
Johnson: We frequently
separate our discussion of health disparities for minorities and
women, and in fact we should be merging those discussions so that
we are talking about the full range of women. Women are facing
many of those same issues, and minority women tend to experience
challenges in an even more profound way - issues around coverage,
issues around access to care.
There are some particular
pieces in terms of access and coverage that women experience because
of their unique biology. For example, transitions in care or coverage
due to pregnancies, especially if you are in a lower income job.
Coombs: Also, maternity,
in terms of prenatal care, is crucial for mom and baby to have
a healthy outcome. If they are skipping on prenatal care for various
reasons and they're not getting what they need, that results in
two people ending up having a poor outcome.
Johnson: That is a
very important point. It gets to this looking at care and health
across the lifespan. If you look at this issue of prenatal care:
How do we think about our young women before they get pregnant,
which is a very large determinant of how their pregnancy is going
to end up.
Obesity is a significant
risk factor, for example, for gestational diabetes (diabetes that
occurs during the pregnancy), as well as for high blood pressure
(hypertension) of pregnancy. Both of these become significant
risks for the mother in later years for developing cardiovascular
disease. Also, it puts the child at risk for developing diabetes.
Those are issues we can begin and should be looking at early before
the event ever takes place. That is one of the opportunities that
we have today with science telling us that these risk factors
that we only thought were unique to pregnancy really have an impact
over a lifespan. So let's get it early.
Globe: Why do disparities
still exist in health care despite the fact that there's been
so much attention given to the subject?
Johnson: Over 97 percent
of people in Massachusetts have insurance coverage - that is a
tremendous success. We know that the percentages of residents
actually accessing care, who have had a visit to a doctor, has
actually increased significantly. But there are still issues around
access to care. There are still affordability issues that hit
populations that might have more marginalized incomes or be in
more marginalized types of roles. We also need to focus on how
to achieve improved health outcomes. Part of that is equity in
health care delivery.
Betancourt: Disparities
were not created overnight, and they are not going to be removed
overnight. This has been a longstanding issue. These are vestiges
of institutional racism, discrimination, resegregation. The impact
of all these social determents, I would argue, has gotten worse
with the down turn of the economy.
We are making progress
slowly. One thing to note is that national health care reform
is the first time any federal legislation has been put forth where
there are particular and specific disparities provisions. Same
with the health care reform we had in Massachusetts.
My sense is that we're
on the right trajectory. We certainly still have to continue to
do a lot to empower communities, to work toward socioeconomic
justice while at the same time making sure our health care systems
are able to monitor the quality they deliver to patients and make
sure that they are able to identify and adjust disparities when
they become evident.
Globe: Are there health
issues for minorities and women that go ignored by patients and
policy makers?
Coombs: The greatest
frustration is that we will spend 80 percent of our time declaring
our discovery, understanding the statistical inferences behind
diseases and how they exist in our society. But then 20 percent
of the time is how do we get to the point where we actually decrease
disparities? That is essential. And that's the part where the
course for implementation doesn't have the same level of tenacity
as we do discovering these things. My goal or wish would be that,
for instance, with obesity we did a great job releasing the obesity
report in terms of the use. But the next level is how do we get
to the point where we actually make a cultural change from the
ground up to really make a difference? The same thing goes for
teenage pregnancy and HIV infection.
Betancourt: The one
area that receives less attention that needs to receive more is
mental health. Treatment of mental health is challenging. It is
under-resourced. It's marginalized in the United States - period.
The idea of admitting that you might have an emotional and/or
depressive issue is really almost admitting weakness. It's seen
as a weakness as opposed to a truly chronic condition like diabetes
or cardiovascular disease or anything else. The fact that mental
health is marginalized is the number one problem - the fact that
in communities of color . . . seeking mental health treatment
is stigmatized.
I would also say our
mental health workforce is not very diverse. When you have providers
who don't speak different languages and/or who do not look like
patients, mistrust might be an issue.
And finally a lot of
the chronic conditions we are tackling, we find they run in parallel
with depression. We've done some work where we are trying to intervene
on a large group of Latino diabetics and identify a cohort there,
and focusing a lot on giving them diabetes education. We found
out 50 percent of them had depression in the last three years.
You are treating the wrong thing first. You have to get their
mental health right before you can get them geared behind trying
to make improvements around diabetes. That is one area we should
give more attention to. Dr. Alice Tolbert Coombs, President, Massachusetts
Medical Society: `You have to pay close attention to the socioeconomic
impact of where the person lives, where they reside, and what
their income status is, their education level.' Dr. Paula A. Johnson,
Chief of the division of women's health, Brigham and Women's Hospital:
`We . . . need to focus on how to achieve improved health outcomes.'
Part of that is equity in health care delivery.' Dr. Joseph Betancourt,
Director, multicultural education, Massachusetts General Hospital:
`This has been a longstanding issue. These are vestiges of institutional
racism, discrimination, resegregation.'
Watch local doctors
talk about health disparities for women and minorities at
www.boston.com/diversity.
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