Is inequality shortening your life span?
White, Black, or brown, we’d all live longer in a more equal, less status-driven society
Part 11 of an 11-part series on race in America. This is the second part of the piece. The first part was published Oct. 20
By Phillip Longman
Trice Edney Newswire
Michelle Obama’s “Let’s Move” campaign emphasizes the importance of physical activity for combating obesity, a point she has driven home by dancing alongside school kids to Beyoncé’s workout video. But another kind of movement may also be important to your chances of living to a ripe old age: moving to a new zip code.
Between 1994 and 1998, the U.S. Department of Housing and Urban Development conducted a demonstration project known as “Moving to Opportunity.” The project randomly assigned low-income families to one of three groups. Those in the first group received a voucher they could use to help pay the rent on an apartment, provided that the apartment was not in a low-income neighborhood. Those in the second group received a voucher they could use in any neighborhood, while those in a control group received no voucher.
In 2011, HUD researchers published the results in the New England Journal of Medicine. The most dramatic finding was people assigned to the different groups varied significantly in their weight by the end of the experiment. Going into the program, participants as a whole had been substantially more obese than the U.S. population as a whole. But 10 to 15 years later, those women who had moved to more affluent neighborhoods were one-fifth less likely to be obese than those in the control group, and also one-fifth less likely to have contracted diabetes.
This was true even though there was little difference among all the participants in the numbers who managed to move off welfare, improve their education or find a better job. This suggests to researchers how powerfully our surroundings alone are to determining our habits and health. Though it might seem strange to say that obesity is contagious, for example, it does seem that people’s risk of it is affected by the weight of their neighbors, as well as by such environmental factors as whether most of the food for sale in their environs is junk food, as is often the case in America’s most impoverished neighborhoods.
The results of the HUD demonstration project are in line with other studies showing the extreme importance of geography and social environment as determinants of health. A dramatic graphical representation of this reality can be seen in the accompanying map of the Washington, D.C., metropolitan area developed by the Commission to Build a Healthier America. It shows how life expectancy improves by nearly a decade within just a few stops along the region’s various Metro subway lines.
In 2002, the Institute of Medicine published an oft-cited and controversial report entitled Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. The report concluded members of minority groups, even when fully insured, tend to receive substandard care from their doctors. It cited disparities in how often whites and minorities received even routine medical procedures, as well as how often they underwent specific operations, such as coronary artery bypass surgery.
The resulting headlines were sensational — “Is Your Doctor a Bigot?” asked one. And there soon followed fulsome denunciations of the report’s conclusions, notably by Dr. Sally Satel and Jonathan Klick of the American Enterprise Institute. In their 2006 book, “The Health Disparities Myth,” Klick and Satel claimed, “(n)ot only is the charge of bias divisive, it siphons energy and resources from endeavors targeting system factors that are more relevant to improving minority health.”
Today, both sides in this debate have refined their positions and can point to new information. Professor David R. Williams of the Harvard School of Public Health still criticizes Satel as “coming at it from an ideological perspective.” But, he adds, “I will say one thing in her defense. At the time of the IOM report, our conclusion about the role of unconscious discrimination was based on circumstantial evidence.”
That changed in 2007, when the Journal of General Internal Medicine published the results of a study of residents at four academic medical centers. Participants were asked to review the medical record of an imaginary patient complaining of chest pain. For half the participants, the record included a picture of a middle-aged Black man; for the rest, a middle-aged white man. Participants were asked to rate on a scale of 1 to 5 whether they thought the patient suffered from coronary artery disease, and, if so, whether they believed that the patient should receive a drug treatment known as thrombolysis.
The study also asked participants to complete what are known as Implicit Association Tests, or IATs. These tests are designed to uncover unconscious bias by, for example, asking test takers a series of questions about whether they associate the word “happiness” with the word “white” or with the word “black.” In this instance, the test also asked the residents whether they associated Black patients with being more or less cooperative with a doctor’s orders.
The study found that participants who scored high for anti-black bias on the IATs were less likely to recommend thrombolysis when the Black man’s picture, rather than the white man’s, was included in the medical record, presumably because they believed the Black man would be a less cooperative patient or perhaps less able to pay. The study’s authors concluded that the “(r)esults suggest that physicians’ unconscious biases may contribute to racial/ethnic disparities in use of medical procedures such as thrombolysis.”
While few now dispute that some doctors may consciously or unconsciously treat patients of color differently, both the nature of that bias and its importance in explaining racial disparities in health care are highly disputed. For example, in focus groups organized by researchers to assess the role of race in medical practice, Black doctors were far more likely than white doctors to say that a patient’s race is a medically relevant factor in determining the best treatment.
As one Black physician in a Philadelphia focus group put it, “I think being an African American is a risk factor in and of itself. And, I think when you see an African American then you need to often be more aggressive than you would, and use different standards than you would for the general white population.”
Black doctors were also more likely than white doctors to say that they pay close attention to whether a patient can afford the prescriptions they write, and to consider what the circumstances of their patients’ lives are like outside the examining room. In contrast, white doctors in these focus groups tended to dispute that there is any reason to pay attention to a patient’s race in recommending a course of treatment, and even to warn other doctors against racial stereotyping.
But perhaps in this way, the white doctors were showing insensitivity to racial realities Black doctors know better and are indeed medically relevant. As the organizers of the focus groups concluded, since African Americans as a whole are far more likely than whites to suffer from hypertension and diabetes, it may be appropriate for doctors to take into account at least some population-based probabilities of disease when deciding protocols of treatment to follow. Color-blind medicine isn’t necessarily the best medicine.
The picture also looks different when researchers pan back and look at how widely medical practice varies in different areas of the United States. From this perspective, it is place, not race, that overwhelmingly determines what specific treatments patients receive for specific ailments.
Blacks tend to live in parts of the country that have a disproportionately large share of low-quality providers. But as researchers from Dartmouth Medical School have demonstrated, within poor-quality hospitals, which include not just inner-city “St. Elsewheres,” but often well-known academic medical centers, both whites and Blacks tend to be equally mistreated, often by being subjected to unnecessary surgery and unproven treatments. Moreover, there are some predominantly Black cities, such as Raleigh, N.C., and Birmingham, Ala., which have a long history of institutionalized segregation, but where the researchers did not find racial disparities in treatment, and there are others, such as Jackson, Miss., where racial disparities in care are apparent.
More recently, researchers associated with the Dartmouth Atlas Project have concluded that “where patients live has a greater influence on the care they receive than the color of their skin.” Reform efforts, they argue, should therefore be focused not on the headline-grabbing issue of racial disparities, but on improving the quality of the U.S. health care delivery system in every region where it is poor.
Phillip Longman is senior editor of the Washington Monthly. This article, the 11th of an 11-part series on race, is sponsored by the W. K. Kellogg Foundation and was originally published by the Washington Monthly Magazine.