Health care’s color lines
Marshall Chin aims to root out racial and ethnic inequality at the doctor’s office.
By the time medical-school rotations brought Marshall Chin into San Francisco’s free clinics and VA hospitals, he knew what to expect: chronically ill patients—many of them racial and ethnic minorities—with little money and few resources. An internist and associate professor of medicine at Chicago, Chin grew up outside Boston, the grandson of immigrants who arrived from southern China in the 1920s. “My dad’s side of the family was laundry, and my mother’s side was noodles,” he says. Neither side was rich. “As a kid we used to visit my grandparents in Chinatown almost every weekend, so I saw up front the issues of an economically depressed neighborhood—what can happen if you don’t have the best opportunities.”
Physicians who do not share their patients’ racial and ethnic backgrounds, says Marshall Chin, may “miss the boat” when trying to communicate.
As a medical student at the University of California, San Francisco, in the late 1980s, Chin steered his rotations toward the underserved. He spent much of his time at the public San Francisco General Hospital, where he encountered “some pretty bad things,” he says. “People who didn’t have the resources to take care of themselves, social problems like poverty, teenage pregnancy, gang violence, the breakdown of the family.” Many patients were minorities with chronic ailments—heart disease, diabetes, asthma, hypertension—who didn’t fare as well as white patients with the same illnesses. “You see this,” Chin says, “and it gnaws at you.”
In the years since medical school, that gnawing has prompted Chin to investigate how, and how often, medical care breaks down along racial and ethnic lines. In journals such as Diabetes Care, American Journal of Preventive Medicine, American Journal of Public Health, Annals of Emergency Medicine, Quality & Safety in Health Care, and the Journal of General Internal Medicine, he has chronicled osteoporosis rates among Chinese-born Chicagoans, emergency-room wait times for inner-city patients, and logistical hurdles impeding community health centers. In one survey he found that only 18 percent of adult African Americans with diabetes regularly received all seven primary preventive services: glycosylated hemoglobin and lipid tests, blood-pressure measurements, foot and eye exams, dental checkups, and counseling. In another study he discovered that 10 percent of inner-city patients arrived at the emergency room with “inappropriate” prescriptions. “Health disparities,” he says, “are a pretty pervasive problem.”
Since October 2005 Chin has headed Finding Answers: Disparities Research for Change, a three-year program launched by the Robert Wood Johnson Foundation to stamp out racial and ethnic inequalities in medical care. The program is funding $6 million worth of research and interventions for three ailments with strong histories of unequal treatment and clear standards of care: depression, diabetes, and cardiovascular disease. The existence of health disparities is well documented, Chin says, but “an amazingly small amount is known about what actually works to reduce or eliminate” them.
He traces the inequalities’ seeming intractability to several interlocking causes. Poverty plays a major role—more likely to be poor, minorities more frequently lack health insurance, easy transportation to clinics, or jobs that allow time off for appointments. Yet the sheer magnitude of patient diversity also heightens disparities. Among Asians, for example, Vietnamese health problems differ from Chinese or Laotian; Southern African American culture contrasts with Midwestern or Northern; Puerto Ricans are distinct from Cubans or Mexicans. “And then,” says Chin, “there are different socioeconomic strata, different waves of immigration, whether you’re part of 19th-century immigration or 20th century or 1950s or more recent.”
Adrift in this cultural ocean, physicians often fail to grasp minority patients’ belief systems, cultural habits, or economic restrictions. Sometimes they communicate poorly. “We’re all limited by our personal experiences,” Chin says. Compassion and kind intentions don’t always keep health-care providers from “missing the boat” on cultural concerns. “I could say to a diabetes patient, ‘You’ve got to check your sugars every day and take your medications,’” Chin says, “but maybe there are financial barriers. Maybe it’s difficult to procure a low-salt, low-fat diet because of cultural issues, where certain foods are the norm within the family.”
It doesn’t help, he says, that physicians often don’t look like their minority patients. Although blacks, Latinos, and American Indians make up a quarter of the country’s population, they are only six percent of practicing physicians, according to the Association of American Medical Colleges. Attempts to roll back medical-school affirmative action widen the gap, Chin says, since “on average, minority doctors are more likely to practice in underserved, minority populations.”
In part because of their cultural differences, some minorities distrust physicians, Chin says, “and often for very good historical reasons.” Many African Americans, for instance, have not forgotten the 1932–72 Tuskegee Experiment, in which the federal government let poor, black syphilis sufferers die untreated. That distrust leads some minorities to forego a regular physician—the very thing, Chin says, that could dispel their worries. “A regular primary-care doctor,” he says, “will have a better sense not just of your medical history but your attitudes and beliefs, what’s happening at home, what’s happening in your community. That breeds better care.”
As does financial support. By rewarding improved minority care, public policies can encourage health-care providers to reduce inequality within their own practices. “Doctors, nurses, hospitals, clinics—they want to do the right thing,” Chin says,
“but unless solutions are financially and politically sustainable, it’s not going to get done.” Without careful calibration, however, initiatives meant to bolster health-care quality can end up undermining it. Chin cites New York State’s pay-for-performance program compensating providers who hit target numbers for checking diabetic patients’ blood pressure, cholesterol, and sugars. “It’s easier if you’re serving rich, white, well-educated populations,” he says, “than if you’re trying to reach impoverished, vulnerable populations.”
Ending health disparities will require solutions with “multiple levers,” Chin says: information systems to track patient care, physician teams to pack several exams into one patient visit, community health workers, cultural training, and patient education. This past year, Finding Disparities received 178 proposals from hospitals, universities, health plans, and public-health services seeking to address diabetes-, depression-, and cardiovascular disease-related disparities. The program awarded 11 grants totaling $2 million. Among the recipients were Oklahoma’s Choctaw public-health service, which will fuse conventional diabetes care with traditional American Indian beliefs, and Yale’s medical school, which will reach inner-city women with depression by approaching them at their children’s pediatric clinics.
Similar initiatives are under way at Chicago, says Chin, who helped organize a pilot health-disparities course for incoming Pritzker students. Taught by Chicago internist Monica Vela, MD’93, the course combined classroom assignments with visits to South Side clinics and conversations with patients. Sixty-five of 104 students came to campus a week early to attend, and the class quickly became the curriculum’s highest-rated. Next year’s course is already on the schedule. Says Chin: “We need more classes like this.”