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Diversity Boston

Critical care

Women and minorities have been overlooked by the Health system, but what can we do?

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December 5, 2010

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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.

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