“Where do you go for healthcare?” I asked a group of African American participants whom a local pastor had gathered together at a neighborhood church in inner city Dayton.
The year was 1990 and I was running community focus groups for a Wright State University School of Medicine pilot initiative to identify the healthcare needs and barriers among the city’s indigent population.
An elderly woman turned to me. “Honey,” she said, “I get into a tub of hot water and pray.”
I’m reminded of her response whenever the current healthcare crisis lays bare the inequities that continue to haunt the American healthcare system for communities of color.
The individuals in those community health focus groups of thirty years ago had no health care at all, a sobering fact that one participant drily summed up, saying, “You must be very dense to ask people in this community to describe their healthcare status.”
Many people in those inner-city communities, like the woman who sought relief in prayer, spoke of turning to religion, herbal teas or home remedies to find healing. When these failed, they went to local emergency rooms or trauma centers to find medical help.
It was clear from those conversations that those focus groups were the face of underserved minority communities who had little or no access to healthcare systems or providers. An unforgiving mix of financial insecurity and limited or no health insurance gave few if any, a chance at the healthcare services to which more privileged members of society had easier access.
But what quickly became evident, was that the community did not trust the healthcare system because they perceived the cultural bias within it.
“Everything boils down to economics,” said a participant. “Where the dollars are, is where the healthcare providers are.”
It appears that little has changed since then.
That cultural bias exists, said Dr. Tung Nguyen at an EMS media briefing on June 19, because, the ‘default position’ in the American healthcare system is that healthcare is designed to give medical attention to average, ‘default’ patients who happen to be primarily “white, English-speaking, employed and well educated.”
So, as a result of “building a public healthcare system that is based on a racist principle of what works for white people,” said Dr. Nguyen, minorities have paid a terrible price in the coronavirus crisis.
The pandemic has upended the health and lives of people everywhere, but in the US it has unmasked systemic inequities in the medical infrastructure that undermine how communities of color access their healthcare. Data from the COVID-19 crisis is revealing the chasm between those who do and don’t get healthcare, and how race and ethnicity affects who survives or succumbs to the coronavirus.
Racial and ethnic disparities are “even more marked” in data examining COVID deaths, said Dr. Nguyen, a Professor of Medicine at the University of California (San Francisco). He was referring to a Brookings Institute report which showed that Black and Hispanic/Latino people are experiencing some of the highest fatality rates from COVID-19, compared to white people.
Dr. Nguyen pointed out that in the age group 35 to 44, “the risk of dying is ten times more for blacks and 8 times more for Latinx compared to non-Hispanic whites. For ages 75 to 84, the risk is 4 times more for black and 2 times more for Latinx.”
The Brookings data also showed that among those aged 45-54, Black and Hispanic/Latino death rates are at least six times higher than for whites. In April, 70% of Louisiana’s COVID-19 fatalities were African American while in Michigan, Detroit’s primarily black tri-county area accounted for nearly 85% of the state’s COVID-19 deaths.
That trend was also confirmed by a recent CDC report showing that the coronavirus hurts racial and ethnic minority groups at higher rates across every age group. The data shows that African Americans and Latinos are at increased risk of getting infected, being hospitalized, or dying from COVID-19. African Americans are 5 times more at risk, and Hispanic or Latino persons are 4 times more at risk from COVID19, than white persons.
The numbers don’t lie. Minority communities are getting hit hard and it’s time to reset the ‘default position’ in American healthcare.
America has approached public health the wrong way for years, argues Dr. Nguyen. The healthcare infrastructure is wasteful. Despite flaunting the most expensive healthcare system on the planet, a Commonwealth Fund study put the US at the bottom of 11 developed countries ranked on healthcare.
A John Hopkins report found that Americans spent more money ($9,892 per person) on healthcare but received a lower standard of care compared to other developed nations; ($ 7,919 per person in Switzerland) in 2016.
The US has the worst life expectancy among comparable countries. For example,, the United States ranks 29th in infant mortality and 26th for life expectancy, with an average life expectancy of 79 years among 35 OECD countries.
“The reason is that we spend money on the wrong things, and we are wasting money for the outcomes we get,” explains Dr. Nguyen.
Public health should focus instead on factors that contribute the most to low life expectancy, such as “ income equality, low levels of education, exposure to violence, along with other key determinants like employment, housing and food security, and climate change.”
“These are the proper topics for public health to work on in the future” he suggests.
Going back to normal after the pandemic will depend on making effective structural changes to the patchwork US healthcare system. It will be a Herculean task to reinvent the healthcare infrastructure after the COVID19 crisis, but the future of American public health must ensure that race and ethnic disparities inform its outcomes.
By 2045, non-Hispanic whites will no longer be the majority, so spending money on the ‘wrong things’ and looking at health disparities as an afterthought “will not work as a path to the future,” Dr. Nguyen advised.
“My slogan for this is that there is no health quality without equality.” He recommends addressing the disparities in the healthcare system first to raise the quality of care.
He pointed out for example, that metrics for healthcare quality which look at disparities, only work when the metrics are broken down by race and ethnicity.
“So, if an average healthcare metric like “the number of people with hypertension who have blood pressure control,” is not broken down by race and ethnicity, it becomes meaningless because it only represents an average for everybody. In the future, national measures for quality will need to report it by race and ethnicity to have value.
The pandemic has exposed how racial and socio-economic disparities affect access to healthcare in 2020. If advances in medicine and healthcare practices in the last thirty years remain out of reach for every American, just as in1990, then the fragmented healthcare system is unfair and outdated. It’s certainly unworthy of the hefty price tag attached to it. The future health of Americans is in jeopardy unless we build a public healthcare system that switches the ‘default position’ of who gets healthcare, from white, to one that reflects the changing face of multi-ethnic America.
“As the saying goes, we shouldn’t waste a good crisis,” urges Dr. Nguyen. “Some good needs to come out of the pandemic.”
Meera Kymal is a contributing editor at India Currents
Photo by Adli Wahid on Unsplash