"Health Disparities and Inequity in the Era of Health Reform: Why Internal Medicine Must Lead the Way."
Wayne J. Riley, MD, MACP
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Video: View Dr. Riley's keynote speech from Internal Medicine 2012. |
There is an often told story in New Orleans….. about a two neighbors who lived side by side by for many many years in one of those typical "shot gun" houses found in just about every area of this city.
This man and woman were excellent neighbors and friends who would look after each other, watch over the homes, pick up their mail and packages, and sometimes cook for each other particularly that staple of every New Orleanian's diet Gumbo…. and provide support to each other
As fate would have it….one day the male neighbor passes away....and in grand New Orleans tradition….there is a large, boisterous wake service held in a local funeral parlor…..and it is filled with the deceased extended family and friends, co-workers and dozens of flower bouquets and floral arrangements.
About mid way thru the wake, his grieving neighbor appears at the door of the funeral parlor holding what appears to be a large pot….
She steadied herself and began to weave her way thru the crowded funeral parlor of astonished friends and family and headed straight for the open casket where her friend and former neighbor lay in repose.
She walked right up to the edge of the casket and "plopped" the pot on the very edge of the casket
Now this scene was just too much for the presiding minister as he watched this woman make her way towards the casket…..whereupon he made a bee line towards the woman….and proceeded to ask her…..Madam, what in the world would lead you to bring a pot of god knows what to your former neighbors wake.
The woman gazed at the minister…and then the open casket of her friend and said….Reverend, if my dearly departed friend can smell of these lovely flowers….he can eat my damn gumbo!!
Moral of this story is that as we know if New Orleans….you should enjoy the bouquets that come your way while you can enjoy them….and colleagues I am honored to be with you today to speak to you about an issue near and dear to my heart and life's work.
Good morning and welcome to New Orleans…..
….The Crescent City, NAWLINS, the City that Care forgot, NOLA, Hollywood South, The Big Easy…. or whatever you choose to call it ….I just call it home….and isn't it great to be back in New Orleans!!!
….yes it is …at a time when my beloved hometown is being reborn…rebuilt….renewed ….and reinvigorated….. after Hurricane Katrina….the mighty storm for the ages knocked it to its knees and caused so much strife, misery, pain and struggle.
But, this is a city imbued with an amazing spirit of resilience and perseverance that we all can admire and emulate in our work of service as physicians.
Now…..Just a few short miles away from here………..there is indeed a different New Orleans…..where the "glitter just doesn't shine"… and for which the health and well being of many is not very good at all.
And so as we gather in this great city, the city of my birth and formative years in our much anticipated spring ritual ….if you will…. our super bowl…. final four…. or the Stanley cup, if you will….. of our great specialty of internal medicine …..where we come together to hail embrace numerous advances in the treatment of disease …. gain insight into best practices…. and be mesmerized and enchanted by the newest technology that can easily fit within our white coats and we hope….get into our offices, clinics and hospitals quickly.
While I too look forward to being refreshed, reinvigorated and reenergized at our annual sessions…..there is a worrisome- and I would suggest thorny reality faced by many Americans….some who reside not too far from where we sit this morning…..that no matter how edified we leave him at the end of this exciting and glorious week….it will not matter to those in our communities who grapple and face stark, real and frustrating health inequity and healthcare and health disparities ….and no amount of sugar coating will obscure the fact that wide swaths of populations in this town… and yours…will likely never benefit from all that we will take in and learn this week.
The sobering facts are these:
- At no time in U.S. history has the health status of minority populations equaled or even come close to that of whites.
- Just about all racial and ethnic minorities experience higher rates of illness and death than non minorities.
- African Americans are four times more likely to undergo a leg amputation or develop peripheral vascular disease.
- The age adjusted death rate for the black population is 26% higher than that of the non Hispanic white population.
- Hispanics are less likely than non Hispanics to receive major procedures in 38 of 63 different disease categories.
- African Americans are significantly less likely than whites to receive major therapeutic procedures in 77 disease categories.
- African Americans with coronary artery disease or history of heart attacks are significantly less likely than whites to reciveve appropriate procedures or therapies.
- Minorities are less likely to be given appropriate cardiac medications or undergo bypass surgery.
- African Americans are less likely to receive recommended cardiovascular medications like beta blockers, anticoagulants or a simple aspirin
- 25% of the hospitals that are the most crowded care for nearly 90 percent of elderly African Americans
- Hispanics are almost twice as likely as non Hispanic whites to die from complications of diabetes
- Native Americans disproportionately die from diabetes, liver disease, cirrhosis and unintentional injuries
- Racial and ethnic minorities suffer from worse health and receive lower quality care than whites-regardless of how much money they make, where they live or whether they have insurance coverage
- Even when access to care is equal, racial and ethnic minorities tend to receive a lower quality of care than whites
- And to add insult to injury….people from communities of color are more likely to be uninsured - 32% of Hispanics, 21 per cent of African Americans and 17% of Asians are uninsured compared to the rest of the population….
I can put this in no better context than was done by a distinguished Master of the college and the President of the Robert Wood Johnson Foundation when she related a true to life story about a patient she had encountered at a community health clinic not too far from her office in Princeton New Jersey….Mrs. Jones a 56 year old African American women diagnosed with diabetes with strong family history of diabetes which had led to the amputation of her mother's foot some time in the past.
When Mrs. Jones showed up to the clinic struggling to walk, examination revealed that her left great toe was badly infected….her blood sugar was over 600 and her HBA1C was 13. She was told that she had to go to the hospital immediately….she burst into tears, not because she badly needed to work because she was paying off a six thousand dollar bill for a previous preventable hospitalization….Mrs. Jones is employed in one of the toughest and most difficult occupations - she works as a full time home health aide for elderly and disabled patients….she was upset and emotional because she worried about what would happen to her patient is she did not show up…and Mrs. Jones always showed up.
The economics of her problem will sound familiar:
- She could not afford the chem. Strips to test her blood sugar,
- Could not pay the out-of-pocket costs to get her feet check regularly,
- Could not take time away from work to wait in long lines for what little charity care might be available
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Her choices were as simple as they come
A healthier life vs. livelihood itself
Now I know each and every one of you have encountered a Mrs. Jones…who made us feel helpless….even though we knew what to do….all the right tests to order…and referrals to make.
With all our training, all our technology - even with all the arsenal of drugs and therapies at our disposal….she needs us to help figure out a system than can serve her others like her better.
This case and far too many like it reflects the sobering reality that when we view the spectrum of medical practice….in our great, ethnically, culturally and racially diverse "gumbo" of a nation…it is very clear that outcomes of our treatment are very good in general…but are woefully inadequate and disparate….and even more concerning…is that treatments are often applied unequally and lead to marked health care disparities….
Case in point, an example that hits right here at home in the ACP.
It was at this meeting in 1996 that Kevin Schulman and colleagues highlighted that fact that subtle bias is sometimes present in the way even we internists and other family physicians when it comes to being presented patient vignettes with similar symptoms and the different rates that recommendations for cardiac catheterization experienced was influenced in a negative way how patients managed chest pain.
This interesting phenomenon is captured in the different views among physicians and the general public about treatment decisions.
The perspectives in physicians of different racial/ethnic backgrounds are sobering: Anywhere from 54 - 89% of physicians clearly do not think that African Americans with heart disease are just as likely to get specialized medical procedures and surgery. Now to put it further in context….this month marks the 44th anniversary of the death of one of our greatest Americans.
Dr. Martin Luther King Junior who reminded us in 1966 that of all the forms of inequality, injustice in health is the most shocking and the most shocking and the most inhumane.
Now I could go on and on…but I suspect that you get the point…..we have a lot of work to do….and in my view….the House of Internal Medicine must assume to mantle and burden of leadership….because if not us who….and if not now when. Along me to be a little "jingoistic" to emphasize this point
….we are INTERNISTS….the physicians who are trained best to forge therapeutic alliances with our patients, inform policy makers and encourage our patients to get all the care they need….and no more than they rightfully deserve….no matter their race or background, their sexual orientation or where they live.
We can and must do better….because we know better
…..This is our calling….this is our task…..to address in a forceful, comprehensive, coordinated and cost effective way the rampant disparities which renders too large a portion of the population of our great country unable to enjoy their lives…their communities…and their full potential as fellow citizens.
In spite of the rancorous and sometimes silly debates about health reform that we have witnessed over the past two years….it is an incontrovertible fact that the a major step in addressing and fixing health care disparities is for the 30 million Americans, approximately half of which are black, Latino and minority get an insurance card in their hands….it clearly is not the only answer, but it is a start that must take place as we work on some of the other issues to ensure that our patients get the care they need. I am so appreciative and proud of the forceful and effective leadership in your American College and the leadership that represents us so well in leading from the front to support the Patient Protection and Affordable Care Act, embracing cost conscious care and offering real solutions to reform Medicare.
Now as I move to close, I remind you that, New Orleanians….now mark time as being before or after Katrina…A city that will forever mark time in a way that few of us can fully comprehend or even imagine which serves as a perfect backdrop to highlight this discussion….because in many ways it is the classic tale of two cities so well described by Charles Dickens a long time ago
….I also come at it having devoted five years of my professional career before becoming a physician to serving this city as an Executive Assistant to the Mayor of New Orleans….working side by side for long hours and days for the great, good and honorable man for which this cavernous Convention Center is named…Ernest N. Morial, the first African American mayor of New Orleans is one of my life's mentors who set me clearly on a path of service that I am honored to have traveled these many years as I followed my passion to be the best internist I could possibly be and to bring the message of the presence of health inequity and health disparities… to a broader audience.
And so, this week, enjoy the greatness of New Orleans - grab a bowl of gumbo, a few oysters on the half shell, partake in a Sazerac cocktail…or two…stroll through the French Quarter and hear the sounds of jazz that define this city all over the world. And remember that the story of New Orleans can animate our work as Internists to do the work that needs to be done.