The online journal Cancer Epidemiology on Mar. 4 reported that although breast cancer survival rates increased overall between 1990 and 2010, white women benefited far more than did black women. Over 20 years, survival rates for white women had improved 27 percent; those for black women, 13 percent. This study of data from 41 U.S. cities showed that disparities in rates of improved outcome worsened over time, moving from a 17 percent differential in 1990-1995, to a 30 percent discrepancy during the next five years, to a 35 percent difference, and during 2006-2010 to a 40 percent gap.
Cancer biologists know that black women are genetically susceptible to a particularly aggressive form of breast cancer. But results from New York, Minneapolis, Miami, Portland and Las Vegas give the lie to a genetic explanation for the discrepancy in death rates. Dr. Bijou Hunt, the study's Chicago-based lead author, told Reuters that "If genetics were responsible . . . we would not have seen the rates go from being nearly equal in most places at the first time point to being so much worse for black women than for white women at the last time point." Dr. Otis Brawley, the American Cancer Society's chief medical officer, agrees: "Black people in New York are not genetically different from black people in Chicago, but their outcomes are different."
"Most of the disparities are actually due to access to care and access to quality care," Brawley suggests. According to Hunt, "The advancements in screening tools and treatment which occurred in the 1990's were largely available to white women, while black women, who were more likely to be uninsured, did not gain equal access to these life-saving technologies."
Writing in the Mar. 14 New York Times, Harold Freeman, former Harlem Hospital physician and past president of the American Cancer Society, reported that "in 1990, we pioneered the patient navigation program, which provided one-on-one support to patients with abnormal findings.... Applying the two interventions in Harlem - breast cancer screening and patient navigation - [we] raised the five-year breast cancer survival rate from 39 percent to 70 percent in 2000."
For the present writer, who worked as a physician, this report is shocking, but does not surprise. On March 12, 2010 Amnesty International released a devastating document titled "Deadly Delivery, The Maternal Health Care Crisis in the USA." Between 1987 and 2006, the report says, death rates for U.S. mothers during pregnancy and childbirth doubled, from 6.6 deaths per 100,000 births to 13.3 deaths. "African-American women are nearly four times more likely to die of pregnancy-related complications than white women."
According to Amnesty International, "[W]omen face barriers to care, especially women of color, those living in poverty, Native American and immigrant women." As of 2011, 48 other nations claimed maternal mortality rates more favorable than the United States.
It's an old story: African American women are almost twice as likely to die from cervical cancer as white women. Black males are more than twice as likely to die of prostate cancer as white counterparts. In 2010, the infant death rate for black babies was 11.6 first-year deaths per 1000 births; the rate for white infants was 5.2.
Fractured U.S. health care tolerates discrimination. Recommendations for practitioners are in order. First, if and when practitioners find themselves shouldering increased responsibilities for the public's health, they would do well to rely upon tried and true clinical methods, which will retain their usefulness. So, practitioners would continue to prioritize the discovery of causes of people's illnesses in order to know what to do. They would leave no stone unturned in their search. And they would, as always, offer diagnoses and correct treatments to anyone appearing for help. Training, apprenticeship experience, and ongoing peer review undoubtedly will continue to reinforce such precepts.
In the situation presented here, practitioners would find investigation of cause to be no great chore. Demographic and epidemiological data have established the role of race discrimination. Recall of earlier instances of poor health outcomes from the same cause bolster the conclusion. The sticking point, however, is the matter of "anyone." Comfortable in an artisanal mindset, many practitioners say, "I see patients one by one. That's all I can do."
Practitioners ought, therefore, to prepare themselves for extending notions of who they care for. They would think about people away from their hospital or on the other side of their office doors. To broaden their horizons, a push will be required beyond that provided by universalized access to insurance, providers, and facilities. Persisting problems include discriminatory attitudes of some physicians and low quality hospitals serving African Americans. Presumably societal consensus will grow as to meeting the needs of all. If so, an environment may materialize in which practitioners are encouraged to build new capacities, taking on roles, for example, of planning, advocacy, and collaboration,
They ought to know that this prescription is no wild dream. There is a basis in reality. In one way or another, all industrialized nations do offer universal health care - all of them, that is, except for the United States. International health investigator Vicente Navarro has documented how social democratic political parties and labor unions, working in tandem, fought for and achieved such health care systems.
U.S. circumstances are different: "[I]t is the weakness of the working class .., with the absence of a mass-based socialist party and with very low levels of unionization, together with the strength of the capitalist class ... that explains the absence of a comprehensive universal health program in the United States."
Struggle on a broad front for human decency and human rights would set a new stage allowing individual health care practitioners to respond to societal expectations. Class dynamics play a role. According to Navarro, we are to "help to strengthen the labor movement in the United States, and in doing so we should also capitalize on the diversity of the social movements, helping those movements to see the basic commonality of their struggles to unite rather than divide working people. This is, indeed, the best thing you can do to improve the health of our people."