The Elephant in the Room
Written by Ardena L. Flippin, MD, MBA   
 health care disparity

A recent article in the journal Cancer observed that, in spite of declining colorectal cancer (CRC) death rates, this decline is not reflected in African-Americans.  African-Americans continue to have the highest rate of colon cancer mortality, including those African-Americans who have insurance.  This means that, for African-Americans, having health insurance doesn’t ensure receiving the same treatment and treatment recommendations as whites.

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Dr. Chyke A. Doubeni of the University of Massachusetts Medical School noted in his study that when blacks and whites with colorectal cancer are treated the same they have similar outcomes. A 17% mortality rate for African-Americans decreases to 6% when adjustment is made for tumor stage and receipt of surgical therapy.

Dr. Doubeni suggests two reasons for the disparity – advanced stage at diagnosis and providers decreased referrals for surgical treatment of blacks compared to whites.  Studies prior to Dr. Doubeni’s have found differences in treatment patterns by racial/ethnic status.  These studies showed “a consistent pattern of the receipt of less aggressive treatment among nonwhites than among whites, including receipt of any colorectal cancer-directed treatment, adjuvant therapy and follow-up after initial potentially curative treatment.”  (V. Shavers, M. Brown. Journal of the National Cancer Institute, March 2002)

The elephant in the room is why an African-American population that has access and insurance is treated differently from majority populations.  More accountability in data collection is purportedly the basis of recognizing circumstances and trends of health care disparities.  The question is whether the collection of disparity data might make individuals or health care organizations “look as if they perform badly or discriminate.” (Health Services Management Research 19:44-51)

Are providers withholding early screening and appropriate surgical referrals because of race/ethnic bias or prejudice? Or is treatment withheld because of the perception that the patient will not comply?

Patients might not comply because of distrust of the medical system and/or sensing provider bias. Are minorities justified in distrusting the healthcare system? In a 2004 J Gen Intern Med survey, patients said that they felt that “they would have received better medical care if they belonged to a different race/ethnic group, medical staff judged them unfairly or treated them with disrespect based on race/ethnicity and how well they speak English.” (J Gen Intern Med 19:1001-1110)

In addition, providers are not justified in withholding scarce resource referrals from patients, which denies them the value of their insurance dollar; and if patients do distrust the system, withholding resources justifies that distrust. And with African-Americans’ disproportionate share of the 56,000 annual colorectal cancer deaths, it’s like Tuskegee all over again on a grander scale.

As physicians we can “target” certain vulnerable populations or we can accept that, in the words of Dr. Harold Freeman, a senior advisor to the director of the National Cancer Institute, “we make decisions through a very powerful lens of race, which helps determine what assumptions we make about each other, whether we are doctors or not.”

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