Bioethics Perspective I Health Disparities

What are health disparities and why are they ethical violations? Olivia Carter-Pokras and Claudia Baquet discuss a number of definitions that have emerged since 1985, when the U.S. Department of Health and Human Services issued the Report of the Secretary's Task Force on Black and Minority Health. The Task Force defines health disparities as excess mortality of minorities as compared to that of whites. Healthy People 2010, whose goal is to eliminate disparities, defines them as differences that occur by gender, race or ethnicity, education or income, disability, and residence in rural localities. The National Institutes of Health (NIH) defines disparities as differences in incidence, prevalence, mortality, and burden of disease (Carter-Pokras and Baquet).

According to reports from the Centers for Disease Control (CDC), African Americans have higher death rates than whites due to cancers, diabetes, cirrhosis, homicide, AIDS, and cardiovascular diseases. Maternal death is between three and four times higher for black women than for white women. More white women have breast cancer, but the death rate is higher in black women and is increasing.

The excessive rates of illness contribute to the higher mortality rate of African Americans; the National Vital Statistics Report puts life expectancy for white women at 80.0 years; 74.9 years for black women; 74.8 years for white men; and for black men it is 68.2 years (Arias).

Beginning with slavery and continuing throughout the twentieth century, a persistent and disturbing gap has characterized the health status of African Americans and whites. At emancipation public health officials predicted that freedom would lead to the extinction of the former slaves, who did, in fact suffer numerous health problems, including tuberculosis, malaria, excessive malnutrition, pellagra, and syphilis. The disparities continued throughout the twentieth century and into the beginning of the twenty-first.

A number of reports and policies established goals and recommendations to improve the alarming state of African Americans' health. With the launching of Medicare and Medicaid in 1966, the health of blacks improved, as did that of whites, but the health gap remained. In 1985 the previously mentioned Task Force made recommendations for reducing the disparities. In 1990 the American Medical Association (AMA) Council on Ethical and Judicial Affairs published an influential and much cited article on the disparities. In 1998 President Bill Clinton established the Initiative to Eliminate Race and Ethnic Disparities in health by 2020.

Despite some improvement over the years, the health gaps persevere and in some instances have gotten worse as the twenty-first century began. In 1970 infant mortality in blacks was twice that of whites; at the beginning of the twenty-first century, black infant mortality is still twice that of whites. In 1970 deaths due to asthma were about three times higher in blacks; at the beginning of the twenty-first century, deaths due to asthma have increased: They are now five times higher than in whites (Centers for Disease Control, 1996). Researchers Robert Levine and his colleagues report that the disparities have not improved since the end of World War II, despite decades of funding for health-related programs.

Some observers attribute the health gap to biology, suggesting that excess infant deaths and disproportionate incidences of lung cancer and breast cancer deaths are due to genetic differences. Others attribute the high rate of sickness and death to irresponsible lifestyles. According to this explanation, African-American women and men refuse or neglect to get timely cancer screenings until it is too late to curb the spread of the condition, or they prefer to smoke high-nicotine content cigarettes and drink high-alcohol content liquor that increase lung and liver disease (Moore, Williams, and Qualls). Still others attribute the disparity in health status to cultural attitudes and deficits that prevent health-seeking behaviors that take advantage of available health services; patient and family beliefs at variance with those of medical professionals; and negative attitudes toward healthcare providers. This explanation, for example, asserts that African Americans prefer dialysis to a kidney transplant (Ayanian et al.). In particular, many authors single out suspicion of the healthcare system as a barrier to seeking care. Indeed, many African Americans fear that they will become guinea pigs for unethical medical research (Thomas and Quinn; Dula).

Health researchers are beginning to acknowledge that health disparities do not merely reflect class, lifestyle choices, or genetics. They are also a result of current and accumulative racism and discrimination in U.S. society (Peterson et al.). Yet the word racism is grudgingly used even though it is a statistical fact that one's race often determines the quality and quantity of services, procedures, and healthcare that one receives. Health disparities must be understood as a bioethical issue if they result in more sickness and shorter life spans for African-American populations as compared to white populations. If these disparities are a result of racial discrimination, they ought to be ethically unacceptable in a just society.

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