The Differential: The health implications of being African-American
Chief of the Division of Hematology, Sylvester Comprehensive Cancer Center,
University of Miami
These past couple of weeks have been times for reflection for me on race relations in the U.S., and the pervasive racism that persists despite the transformative presidency of Barack Obama. As a white male, I can’t pretend to truly understand what it must be like to be a person of color in my country, so I have dedicated myself to read the writings and listen to the oratory of those who are, in an attempt to learn, listen, accept and love, hopefully empathize, and to recognize the unconscious bias we all carry. One particularly moving editorial by former basketball star Kareem Abdul-Jabbar has helped me, and I’ll leave you with a quote from that piece:
“Racism in America is like dust in the air. It seems invisible—even if you’re choking on it—until you let the sun in. Then you see it’s everywhere. As long as we keep shining that light, we have a chance of cleaning it wherever it lands. But we have to stay vigilant, because it’s always still in the air.”
- Mikkael Sekeres
THE RACIAL DIVIDE IN HEALTHCARE
Editorial Note: All terms to describe race derive from the source article.
1. The COVID-19 pandemic has highlighted the racial disparities that are so deeply entrenched in healthcare.
Emerging data on the impact of ethnicity in COVID-19 suggest that Black patients, and those of Asian and minority ethnicities, are at increased risk of acquiring SARS-CoV-2 infection when compared to White patients, and, once infected, have worse clinical outcomes. Read the study
2. In Louisiana in the U.S., despite comprising just 31% of the patient population, 77% of those hospitalized with COVID-19, and 71% of those who died were Black. Once hospitalized, Black race was not independently associated with an increased risk of death, suggesting that other factors were responsible for the disproportionately high rates. Black patients were more likely to present with signs of severe illness, and were also more likely to require intensive care and mechanical ventilation. Read the study
3. The racial health divide extends beyond COVID-19. It has even permeated into hospital software.
In the U.S., the algorithm powering widely-used hospital decision-making software to help identify patients with complex health needs has been found to significantly discriminate against Black patients. Black patients were less likely to be referred than White patients, and were also considerably sicker than White patients at any given risk score. The bias is the result of the algorithm predicting healthcare costs rather than illness, further exacerbating the unequal access to care Black patients face. It is estimated that remedying this disparity would increase the percentage of Black patients receiving additional help from 17.7 to 46.5%. Read the study
4. Police killings have spillover effects on the mental health of Black Americans.
Unsurprisingly, police killings of unarmed Black Americans have adverse effects on the mental health of Black American adults, with the largest effects occurring in the 1-2 months following the events. The negative impact on mental health resulted only from police killings of unarmed Black Americans (not unarmed White Americans or armed Black Americans), and was not observed among White Americans. Read the study
5. Negative encounters with police translate to medical mistrust.
African-Americans face higher rates of negative encounters with police and episodes of police brutality. These encounters, even when perceived to be necessary, result in higher levels of mistrust in medical institutions.
RACIAL BIAS IN HEMATOLOGY-ONCOLOGY
1. Multiple myeloma illustrates the racial differences in disease incidence and outcomes.
African-Americans are twice as likely to develop multiple myeloma than their White counterparts. Despite potential improved cytogenetic risk factors leading to greater disease-specific survival in African-American patients, overall survival is usually lower than that of White patients, a difference that disappears when access to care is equalized. Additionally, African-American patients with multiple myeloma are less likely to undergo stem cell transplantation than older White patients. Read the review
2. Black people are under-represented in oncology trials.
Despite making up 13.4% of the U.S. general population, Black people accounted for just 3.1% of participants in FDA clinical trials that led to cancer drug approvals between 2008-2018, only 22% of the expected number based on their cancer incidence. Read the study
3. Beyond that, African-Americans are under-represented in medical oncology. In 2013, only 2.3% of oncologists, and 4% of hematology-oncology fellows, in the U.S. were African-American. In 2015, the American Society of Clinical Oncology (ASCO) released data showing that African-Americans will likely continue to be seriously under-represented in medical oncology.
As African-Americans experience a greater incidence of cancer and higher mortality rates compared with White people, this under-representation in medical oncology has significant implications. Studies have found that African-American patients ask less questions and are less likely to participate in decision-making when their physician is non-African-American. Physicians in those visits are more verbally dominant and tend to provide less information. In contrast, African-American physicians often demonstrate less racial bias than their White counterparts. Increasing the number of practicing African-American physicians can be a helpful strategy in reducing the impact of racial bias and disparities in healthcare. Read the comment
THE ROLE WE ALL PLAY
By: Jonas Attilus, MD, MPH
We need to identify how we benefit from the system, and then use our privilege to fight for equity.
"We become physicians because we work hard and show a lot of resilience. Nevertheless, we are among the most privileged people. We cannot stay indifferent to the lives of those we care for.”
This was originally published in the June 11, 2020 edition of our Differential: Hematology newsletter. Receive the latest clinical cases and top stories in hematology-oncology directly to your inbox. Subscribe now.