Miami Herald - September 13, 2004
John Dorschner, jdorschner@herald.com

For more than two years, stacks of reports have been piling up about what has become a raw, festering wound on America's social conscience. Dozens of studies make the point: Even if minorities have good health insurance, they tend to get worse healthcare, and they're much likelier than whites not to have good insurance or any health insurance at all.

"We're sick and tired of being sick and tired," said Donna Christensen, a physician who represents the Virgin Islands in the U.S. Congress. "We came here to issue a call to action."

She said whites with good insurance should pay attention to what's happening to minorities because it ultimately hurts them, too. "We're getting to the hospital late, using much more expensive care," Christensen said. "We're really driving up the costs of healthcare."

Hospitals and doctors make up for those higher costs by charging more to those with insurance.

LITTLE COVERAGE

One or two television crews dropped by the meeting room at Miami Dade College's downtown campus to listen to the members of Congress -- a rainbow of blacks, Hispanics and an Asian-American. The crews got a quick sound bite for a slow Saturday and vanished. A lone print journalist listened to the passion being voiced by the participants.

"This is deep," said Elijah Cummings, a Baltimore congressman and chairman of the Congressional Black Caucus. The Democrat cited one report: In a study of 26 million Americans, even when adjusted for income and insurance, black males were 3.6 times more likely than whites to have an amputation and 2.4 times more likely to be castrated.

Those figures were contained in a 562-page report from the Institute of Medicine called "Unequal Treatment," published in 2002.

LIFE SPAN ISSUE

The biggest disparities appeared in the life span of males: Black males live seven years less than white males. Hispanics live five years less. That basic gap hasn't changed in half a century.

"Unequal Treatment" caused a public outcry. Medical schools, including the University of Miami's, started "cultural competency" classes to teach students to be sensitive to minorities. The healthcare industry vowed to make changes.

Still, when the minority representatives gathered in Miami, they shared a feeling that the situation didn't seem to be improving.

One solution, voiced by many, was to get more minority doctors. But in fact, because of rollbacks in affirmative action programs, the number of blacks entering medical school dropped six percent in 2003 and the number of Hispanics declined four percent, according to the Association of American Medical Colleges.

Even worse, a new study shows that minority physicians also have a problem. A team, led by Peter Bach, reported last month in the New England Journal of Medicine, that black physicians surveyed complained that they have greater difficulties than white doctors finding high-quality subspecialists for their patients or getting them admitted to hospitals.

These kind of disparity problems are subtle and hard to personalize. Much easier to identify are those who suffer clear-cut economic disparities.

GETTING BY

For Henrico St. Fleur, an 18-year-old North Dade resident and the son of Haitian immigrants, it's a matter of eyeglasses that he can't afford. A part-time student and free-lance photographer, he doesn't have the money for health insurance either. "So I just get along."

For Alex Martinez, 43, of Homestead, it was a matter of ignoring his diabetes. "I was between jobs, so I had no insurance." For six months, he didn't take medications or check his blood sugar levels. "Medicine is expensive and I didn't want to deal with that. I was sort of in denial."

For Sofia Nunez, 27, of West Dade, it was a matter of feeling tired for several months. She knew she should see a doctor, but she had lost her health insurance when she left her job as a security guard. Later, she resumed working, but this time the company was no longer providing benefits.

She saved her money until she could see a doctor and pay for the $242 blood test that told her she had anemia.

When the congressional members met in Miami, they talked about problems caused by lack of insurance and the special difficulties that immigrants confront.

They also talked about destructive behavior that could be changed: Higher rates of HIV/AIDS among minorities and a greater likelihood that their children will be obese.

And with all their other problems, they were enraged that cigarette companies seemed to be targeting black teens.

Cummings said political leaders could not only pressure the healthcare business for better treatment, but "we also have a bully pulpit with our constituents."

INADEQUATE SYSTEM

Still, the leaders were certain that the biggest problems were with the healthcare system. Several repeated a quote from the Rev. Martin Luther King Jr.: "Of all the forms of injustice, discrimination in healthcare is the most cruel."

What follows is a look at the major problems of minority healthcare in America.

I. AN UNEQUAL

QUALITY OF CARE

Disparities in healthcare range from the outrageous to the subtle.

Cummings, for example, says his grandfather suffered a heart attack in the pulpit of his South Carolina church and was taken home, where he was visited by two white doctors.

According tp Cummings' elders, the younger doctor said to the older one, "Maybe we should take him to the hospital," and the older one said, "Don't worry about him. He's only a nigger."

The grandfather died in his 40s. Cummings' father died, too, from a heart attack while preaching from the pulpit: He was in his 70s and had received better healthcare.

"I'm hoping to do better than my father," says Cummings.

But here's the tricky part. For years, Cummings said, he was treated by black physicians in Baltimore. His blood pressure was running 140/100 "and they thought that was pretty good because most people they saw were 180/115."

Then he switched to a white physician who treated members of Congress. "They wanted to send me to the hospital." He was put on medication that lowered his blood pressure to 115/80.

Cummings is not arguing that white doctors are better. In fact, he thinks it's crucial that America have more minority doctors. His point is that problems of disparities of care are not simple ones.

Consider a study made of 86,000 Medicare heart patients. Even when adjusted for age and gender, the researchers found that whites were four times more likely than nonwhites to be chosen for coronary artery bypass graft surgery. The disparities were greatest in the Southeast, particularly in nonurban areas.

Disparities exist even at a place where everyone has the same insurance, such as the Veterans Administration hospitals, says H. Jack Geiger, a New York physician who has spent years researching disparities.

A study at one VA hospital showed that for something as commonplace as angioplasty, physicians were regularly selecting more whites than blacks. Then the system was changed so that a panel made the decisions based on medical reports that didn't mention race. Disparities vanished.

In some instances, disparities can be explained by geography, says Geiger.

One example: Hispanics are less likely to get hip replacements and knee surgery. The reason is that many Hispanics live in the Southwest, where physicians tend to order those procedures less for all types of patients than do physicians in other areas of the country.

II. THE U.S. SYSTEM

AND IMMIGRANTS

Clutching a piece of cardboard with the number 117, Dulce Javier, 40, sat in the crammed waiting room of the Economic Opportunity Family Health Center in Hialeah.

She lost her health insurance when she lost her job in a Hialeah factory. For a long time, she ignored a throbbing pain in her back, but a friend told her about this government-subsidized clinic, where she could see a doctor for a $15 co-pay.

"That's good," she said, better than healthcare most people received in her native Dominican Republic.

In the crowded waiting room, she was the only one willing to talk to a journalist. More than a dozen others refused.

Vicente Soto, an administrator at the clinic, nodded when a journalist told him that. The unspoken issue is that many patients may be illegal immigrants who don't want to draw attention to themselves.

"Now, we give them a number when they arrive," he said. "So when it's their turn, we just call out the number, not their name. They like it better that way."

The fear of Soto and many other healthcare leaders is that illegal immigrants may postpone treatment because they fear being caught and therefore are more likely to end up as expensive emergency room cases.

Regardless of their immigration status, Hispanics have a tough time with the American healthcare system. They're three times more likely than non-Hispanic whites to be without health insurance.

"Especially in a place like Miami, they're more likely to work for a mom-and-pop type place, and few jobs like that have insurance," says Leda Perez of Community Voices Miami, a group studying health problems of the poor and the uninsured.

In other areas, experts believe that Hispanics may get worse healthcare because of language barriers, but that is rarely a problem in South Florida, says Pedro Jos Greer, a physician who focuses on indigent healthcare.

At the Hialeah clinic, for example, virtually the entire staff speaks Spanish.

III. POOR LIFESTYLE

CHOICES

With unequal treatment and less money to spend on healthcare, some blacks and Hispanics hurt themselves with poor lifestyle choices, and minority leaders find that disconcerting.

Blacks and Hispanics are more likely to be HIV positive, and they're more likely to have overweight kids.

They are, however, slightly less likely to smoke cigarettes than non-Hispanic whites, according to the Oral Cancer Foundation, but tobacco companies seem to want to change that, with aggressive marketing campaigns.

"Part of this is lack of education, and part of this is culture," says Nelson Adams, a North Miami Beach obstetrician who is a longtime leader of the National Medical Association, an organization of black physicians.

Consider obesity: A black non-Hispanic teenage girl is more than twice as likely to be overweight as a white non-Hispanic girl. Hispanic teenagers are also thought to be more likely to be overweight, though exact data is not available.

"There's no single answer," Gervasio Lamas, a Miami Beach cardiologist, told the caucus. "Some of it is greater use of junk food, which tends to be inexpensive, easily accessible and very calorie-dense."

April Young, a social anthropologist who works in Overtown, reported that at two Overtown elementary schools, one third of the children are overweight. Young, who is black and thin, works to stay that way. Every day at lunch, she said, she leaves Overtown "because everything there is fried."

At the minority caucus, retired Congresswoman Carrie Meek suggested that a good place was to start with proper diet in school lunch programs, but Josie Goytisolo of Hispanic Healthcare Communications said more needed to be done.

Particularly those with less education could be easily bewildered by the never-ending conflicts of advice in the media, Goytisolo said. Fruits are good, some experts say, but low-carb folks say they're bad and you should go with fatty meats.

"We need to deconfuse the confused," she said.

The problems with HIV/AIDS among minorities, particularly women, has already been well publicized. "There is in general a lower educational level among minority women infected by this disease," said Ana Puga, the physician who directs the Comprehensive Family AIDS program in Fort Lauderdale.

In Broward, she reported, 87 percent of female HIV cases are black, "and that's almost entirely due to sexual activities. Thankfully, there's a very low rate of needles connected with drugs here."

One problem, said Puga, is that for the more advanced cases, the only solution are experimental drug programs. Sometimes, researchers appear to be more likely to accept whites into these trials, but sometimes, blacks avoid trials because they don't trust them.

"This is a legacy of the Tuskegee syphilis trials," said Puga. "My 9-, 10-, 11-year olds know about Tuskegee."

The Tuskegee trials are notorious for intentionally not treating blacks so they could be compared with whites who did receive treatment -- yet another example of minorities getting worse healthcare.

For the minority congressional representatives who came to Miami, they know that the system is going to be hard to change. Rep. Sheila Jackson Lee, D-Texas, summed up the challenge: "This is an embarrassment. A catastrophe. We need to move mountains."

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