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Disparities in health care exist even when controlling for gender, condition, age and socio-economic status. 2005 American Medical Association >P#P!VWho are African Americans?  VOnly ethnic group here by force Enslaved for over 400 years Punishable by death to be taught to read or write Poll Taxes; Literacy Tests; Grandfather clauses Denied the right to vote until 20th century Number of Countries in Africa: 54 Total Population: 797,769,805 Percentage of World Population: 13.12% Can only trace ancestry to slavery lW ( !'S9Introduction to Health Disparities and African Americans  :8   One thing we must of course expect to find, and that is a much higher death rate at present among Negroes than among whites: this is one measure of the difference in their social advancement. They have in the past lived under vastly different conditions and they still live under different conditions&   What the Negro death rate indicates is how far this race is behind the great vigorous, cultivated race about it. It should then act as a spur for increased effort and sound upbuilding, and not as an excuse for passive indifference, or increased discrimination. THE PHILADELPHIA NEGRO by W.E.B. DuBois, 1899 \7Z0Z6XY African American Plight ,  Every minute of the school day an African American youth gives up on education. Every minute and a half a black baby is born into poverty. Every three minutes a black baby is born to a teen mother. Every ten minutes a black child is arrested for a violent crime. Every four hours a black youth is murdered. Approximately 33% of black elderly live in poverty And every eighteen hours a black youngster dies from AIDS.  Necessity" Special Policy Issue 1994, Summer 1994, 2:1 FZ:Z7[MIn the 2000 Census, 34.7 million people, or 12.3 percent, reported only BlackNN RBlacks account for half of all new infections in the USA, federal statistics show SST'BACKGROUND: IOM Unequal treatment 2002(( The United States has achieved dramatic improvements in overall health and life expectancy, largely due to initiatives in public health, health promotion and disease prevention. However, national data indicate that minority Americans have poorer health outcomes (compared to whites) from preventable and treatable conditions such as cardiovascular disease, diabetes, asthma, cancer and HIV/AIDS. Two factors contribute heavily to these racial and ethnic disparities in health: minorities are subjected to adverse social determinants, and they are disproportionately represented among the uninsured. In the last twenty years, however, the literature has highlighted the fact that racial and ethnic disparities occur not only in health, but also in health care. ZLRespect:  Understanding that demonstrations of respect are more important than gestures of affection or shallow intimacy, and finding ways to learn how to demonstrate respect in various cultural contexts. MShowing Respect C Using Titles ( Mr., Mrs., Dr., Deacon, Rev., etc.) Asking Permission before Touching Avoiding Inappropriate Avoiding Inappropriate Eye-Contact Contact Respecting Personal Boundaries and SpaceJZZ)Z NShowing Respect C Expressing Respect Explicitly  I really admire the way you re raising your children . . .  Honoring Elders and Grandparents Showing Respect for the Culture Seeking to Learn from the patient as Expert in his/her own Culture as Expert in his/her own Culture BZ<OShowing Respect C >Using first name or nickname without permission (Bobby,Kesha), Mom, Sweetie, . . . ..) ۄۄ Touching without permission (Pat on the shoulder, (Pat on the shoulder, grab arm to check rash, etc.) Expressing Expressing Dis Dis-Respect Explicitly Respect Explicitly Lumping Patient with their Ethnic Group Lumping Patient with their Ethnic Group ( most Blacks don t come in until they t come in until they re too sick) PP1  WAssess Health LiteracyHealth Literacy: The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions. -Healthy People 2010- LKWhy We Need Cultural Competence   Rۄۄ We have become not a melting pot but a beautiful mosaic. Different people, different beliefs, different yearnings, different hopes, different dreams. -Jimmy Carter-.P"In order to understand the patientBRace Ethnicity National Origin Geographic Region History Religion CA`2HONDA,2HYPERTENSIVE OVERWEIGHT NEGROES DIABETES ARTHRITISx3$ $ $$$ \<Disparities  Bad for Business]  yEBiDil0BiDil marks the first medication approved by FDA for use in a specific racial group NitroMed officials said that they have set the price for the heart failure medication BiDil at $1.80 per pill -- a higher price, and almost twice the price of rival treatments The company will establish an "unusually generous" assistance program for the estimated 75,000 patients without prescription drug coverage who could benefit from the medication Z5d 0U]vDConcerns with BiDilADavid Magnus, director of the Stanford Medical Center for Biomedical Ethics, said, "There are many, many who claim these use[s] of racial categories may not have any biological meaning, only social meaning, and basing medical decisions on them may be problematic. ... But the more we know genetically, the more we know these social categories don't correspond to genetic groups" "It may be that if this (BiDil's effectiveness) is a race-specific response, it is unlikely to be due to any genetics because people of African origin are extremely diverse" (Baltimore Sun, 6/24). *B5 <-.3d 0Kl;2Higher Blood Pressure Among Blacks is not Genetic 33  The total prevalence in Nigerians ages 35 to 64 is 13.5 percent, in Jamaicans it is 28.6 percent, and in U.S. blacks, it is 44 percent. The study authors conclude the impact of environmental factors among both populations may have previously been underestimated. The total prevalence in Nigerians ages 35 to 64 is 13.5 percent, in Jamaicans it is 28.6 percent, and in U.S. blacks, it is 44 percent. Richard Cooper et al, Loyola University Stritch School of Medicine SOURCE: BMC Medicine, published online Jan. 5, 2005 zZzZB c4Elderly African Americans(Black elderly females who have declining health are frequently sole heads of households More than half of black elderly in America are in poor health noncompliance with medication instructions and schedules Religious beliefs provide a resource for coping with the unexpected or losses (I ll leave it in Jesus hands) JA8M"3African American Physicians 12.3% of the U.S. population is black African American now make up 2.5% of the physician work force African American make up 6.9% of graduates. X. Who African Americans See:  ( 22% see African American doctors 60% see White doctors 18% see doctors of other races Patients' Beliefs about Racism, Preferences for Physician Race, and Satisfaction with Care By Frederick M. Chen, M.D., M.P.H., et al March/April 2005 Annals of Family Medicine 2XX; Diversity and Distrust In a national survey in August, 59% of all Americans said they believe minority patients are more likely than white patients to disregard medical advice or refuse treatment for cultural reasons or because they do not trust the health care system, viewing this as either a major or a minor reason for disparities in care. Responses by ethnicity: White: 54% African American: 74% Source: Harvard University Program for Health Systems Improvementv}ZBZYBk: Tuskegee: The Point of ReferenceZBeginning in the 1930s, 399 men signed up with the U.S. Public Health Service for free medical care. The service was conducting a study on the effects of syphilis on the human body. The men were never told they had syphilis. They were told they had "bad blood" and were denied access to treatment, even for years after penicillin came into use in 1947. By the time the study was exposed in 1972, 28 men had died of syphilis, 100 others were dead of related complications, at least 40 wives had been infected and 19 children had contracted the disease at birth." CNN Interactive Tuskegee Study Website04Z'Z4'2d 04Z!Well-Deserved Mistrust: Tuskegee "" B As hard as that it is to believe for middle-class whites, it is something that is very believable to many black patients. There is also a sense of conspiracy between the white medical establishment and pharmaceutical companies. It comes out in the family context by observing a recognized reluctance to go to doctors, delays in seeking care for serious illness, and reluctance or delays in authorizing surgery. In a national telephone survey of 909 blacks and whites, researchers found that eight in 10 blacks feared they would be used as guinea pigs for medical research. P{PPjPP[PX^ uBA Legacy of MistrustMany African Americans believe that AIDS is a form of genocide, and their fear and suspicion of the health care delivery system is directly related to the history of the Tuskegee legacy African Americans are under-represented as organ donors, under-represented as individuals who donate blood Dr. Stephen Thomas; Dr. Sandra Quinn at the University of North Carolina at Chapel Hill,2005`(]mWxC Consider:  ;clear cooperation of black physicians, nurses, and administrators of Macon County and the Tuskegee Institute Would this study have occurred (especially once penicillin was discovered) if it involved white middle-class Americans as subjects? In spite of the widespread publicity of the Nuremberg trials, there appears to be no suggestion that any of the physicians in the Tuskegee syphilis experiment thought the Nuremberg Code applied to them. Nor, for that matter, has it appeared to have any impact on the development of our own ethical framework in the United States.<ZI%African Americans and Clinical Trials&& @ 52% Percent of all white Americans who are reluctant to volunteer for clinical medical trials for fear that they might be used as guinea pigs in experiments without their consent " 80% Percent of all African Americans who are reluctant to volunteer for clinical medical trials for fear that they might be used as guinea pigs in experiments without their consent (University of North Carolina School of Medicine) @m4n1Y/_African American patients may experience direct or indirect discrimination by white physicians  `^ jstudies have shown that most doctors delay treatment for patients they think are not likely to stick to their drug regimen  with several of those studies indicating that African Americans are among the patients often placed into that category by their doctors. differences are not because of patient's income levels, years of education or insurance coverage. researchers found that African American patients treated by white doctors receive their HIV medications nearly four months later than African American patients being treated by African American doctors. 66Z -=!1Doctor prejudice may be a factor in heart care 22 Unconscious prejudices among doctors may help explain why women and blacks complaining of chest pain are less likely than men and whites to receive the best cardiac testing, a study suggests. Researchers have found such differences in care previously, and have attributed them to financial barriers and differences in patients' preferences, medical condition and access to care. However, a new study of 720 physicians found that, with all symptoms being equal, doctors were only 60 percent as likely to order cardiac catheterization for women and blacks as for men and whites. For black women, the doctors were only 40 percent as likely to order catheterization. P>"0Doctor prejudice may be a factor in heart care11 In the unusual study, doctors attending medical conferences were told they were participating in a study of clinical decision making, and viewed medical data and a taped interview with one of eight "patients." The patients were really actors. There were two black women, two black men, two white women and two white men, divided into two identical groups. In one group, all the patients were said to be 55; in the other group, 70. The actors described identical symptoms. Information such as insurance coverage, profession and results of a heart stress test also were the same. Still, researchers found disparities in doctors' treatment recommendationsPh7Clinical Trials,%African Americans and Clinical Trials&&  52% Percentage of all white Americans who are reluctant to volunteer for clinical medical trials for fear that they might be used as guinea pigs in experiments without their consent 80% Percent of all African Americans who are reluctant to volunteer for clinical medical trials for fear that they might be used as guinea pigs in experiments without their consent (University of North Carolina School of Medicine) DnZ3Zn1{GUnfair Treatment *(White physicians have perceptions that reflect those of white Americans, generally. Regarding the overall fairness of the American health care system, the Kaiser Family Foundation National Survey of Physicians (March 2002) shows that: 25% of white physicians 33% of Asian physicians 52% of Latino physicians 77% of African American physicians & believe that the health care system treats people unfairly based on their racial or ethnic background  very or  somewhat often. 2ZmZZ|HTransplantation Disparities FThe US Department of Health and Human Resources released a report in 1998 on the differences between African American patients and white patients in the months they had to wait to receive a kidney transplant. The difference between the number of months that an African American versus a white recipient had to wait to receive a kidney transplant varied by almost 9 months in 1988 to over 19 months in 1994. More recent data (table below) from the United Network for Organ Sharing (UNOS), shows this trend continuing with a difference in waiting time of 20.7 months in 1997-1998. GZGj9 End of LifeB I just want to die with dignity ""  (At the End of Life, Color Still Divides )) African Americans tend to think of "palliative care" as "giving up hope." I suspect this is so because many African Americans fear their cultural and personal values will not be respected when they are dying. They sometimes worry that their race and socioeconomic status make them more "disposable" and that treatment decisions will reflect that attitude. They do not see palliative and hospice care as offering better care at the end of life. Many worry that palliative care is really a code word for "no care" or "less care." P (At the End of Life, Color Still Divides )) Physicians, nurses and other health care providers in hospital settings should be better educated in pain management and palliative care. This training should include a greater understanding of differences in the way blacks and whites may perceive end-of-life care. African Americans would be more likely to respond positively to providers who are specifically trained to discuss alternatives to life-sustaining treatments with minority-group patients.   !Well-Deserved Mistrust: Tuskegee "" O As hard as that it is to believe for middle-class whites, it is something that is very believable to many inner-city black patients. There is also a sense of conspiracy between the white medical establishment and pharmaceutical companies." It comes out in the family context by observing a recognized reluctance to go to doctors, delays in seeking care for serious illness, and reluctance or delays in authorizing surgery. In a national telephone survey of 909 blacks and whites, researchers found that eight in 10 blacks feared they would be used as guinea pigs for medical research. PPPlPP[PYN)6It didn t end with Tuskegee1951-1960: University of Pennsylvania under contract with U.S. Army conducts psychopharmacological experiments on hundreds of Pennsylvania prisoners. 1952-1974: University of Pennsylvania dermatologist Dr. Albert Kligman conducts skin product experiments by the hundreds at Holmesburg Prison; "All I saw before me," he has said about his first visit to the prison, "were acres of skin." $PZ-Common Myths and BeliefsB Don t let them cut you open  I m not going to be an Organ Donor  He looks like he doesn t like Black people  They took her off the machine because they needed the bed They just want to practice on you with students, he s not a real doctor, yet  AIDS is just another form of genocide ""m< Race Medicine race-based profiling exists in health care and influences providers' clinical judgment dramatic disparities in treatment decisions, and recent work confirms that these disparities cannot be explained away by benign factors like economic status, health insurance status, or condition upon presentation biomedical researchers continue the historical practice of attempting to attribute health differences to race-based biological and cultural differences between Black and White patients excerpted from: Rene Bowser, Racial Profiling in Health Care: an Institutional Analysis of Medical Treatment Disparities , 7 Michigan Journal of Race and Law 79-133, 79-83 (Fall 2001)^Vq? What is Race?A group of people united or classified together on the basis of common history, nationality, or geographic distribution At the genetic level, humans are nearly indistinguishable from one another, 99.9 percent alike. o>Race in Medicine" 'Race' and 'ethnicity' are poorly defined terms that serve as flawed surrogates for multiple environmental and genetic factors in disease causation, including ancestral geographic origins, socioeconomic status, education, and access to health care& Research must move beyond these weak and imperfect proxy relationships to define the more proximate factors that influence health. Francis Collins, the head of the National Human Genome Research Institute (NHGRI)0RRrA!The Problem with Race in Medicine"" fThe notion of race is nearly as problematic from a scientific point of view as it is from a social one. Citing this and other points such as the fact that a person who is considered black in one society might be nonblack in another many cultural anthropologists now consider race to be more a social or mental construct than an objective biological fact @iZZZZgn= The Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT) 19,257 white male patients age 40-79 supported the use of newer drugs, especially in patients with complicated hypertension European Society of Cardiology Congress 2005; Stockholm, Sweden; 3-7 September rZPZ(N1d 0We must not be in Denial_The medical community's long, dismal history of racism and unethical behavior toward African Americans must be acknowledged and corrected. And then we must move beyond this to help African Americans improve access to all medical services, including palliative and hospice care--which will allow us to die "the good death" to which we are all entitled.``Q+Solutions: What can be done Teach doctors to communicate effectively with patients of all races On an individual basis, each physician should follow the recommendation of the American Medical Association Increase the number of minority doctors Community leaders at the forefront Suggested Reading,5D%&Trials, Tribulations, and CelebrationsdAfrican American Perspectives on Health, Illness, and Aging and Loss Edited by Marian Gray Secundy 0ePET,' Prejudice and the Medical Profession (( Racism, Sometimes Overt, Sometimes Subtle, Continues to Plague U.S. Health Care BY PETER A. CLARK, SJ, PhD September-October 2003 Fr. Clark is Professor of Ethics, St. Joseph s University, and Bioethicist, Mercy Health System, Philadelphia@O2nQ+African American Perspectives on HealthcareLoyola University Chicago Stritch School of Medicine Neiswanger Institute For Bioethics & Health Policy Presented by Glenn Ellis - Strategies For Well-Being, LLC February 21, 2006 j7P42  !/"#$%&' /4<?@GO S"U#[$\%]&d)t,-./012356789:;<~ ` 3fffff3̙3f̙` ̙3f` ff3f` f33f3f` 3ffƍ` fff3` f33̙` 3f|>?" dZ@$?lKd@   l@  P`lA n?" dd@   @@``PT   @ ` `p>> H @  ` (  `.T  ` "\\  ` "h ` s *" `  $0e0e BCDELF>5%8c8c     ?1d0u0@Ty2 NP'p<'p@A)BCD|E?|b4"%>Ul @   `c"$  f\  ` "n" ` 0G"r `B T??"  ` <D/=GH "` = T Click to edit Master title style! !*  ` 61= " = RClick to edit Master text styles Second level Third level Fourth level Fifth level!     S  `  `8= ??"`>  = ^*   `  `L== ??"`@a  = ^*   `  `B= ??"\5 = b* B ` s *޽h ? 3fffff3̙3f̙80___PPT10. Capsules   } u 0 d (  dT p d "p d 6?"@  F 0 " d B?G0* "pp  F 0 rZ    d# "  n" dB 0G" R r d T??"L   d < "4 `  ? 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