How med student loan burdens can deepen health disparities

The following article by Caleb Zimmerschied originally appeared on AMA Wire on April 27, 2017.


The high loan burden associated with medical school can discourage students from underrepresented minority groups or lower-income families from pursuing a career as a physician. This creates a ripple effect of widening health care disparities that disproportionately affect the accessibility of primary care physicians in underserved areas.

Adjusted for inflation, the average medical student graduated in 2014 with a loan burden 3.5 times greater than a medical student in 1978. By 2014, the average loan burden was over $170,000.

Higher interest rates and unsubsidized loans for graduate students mean that they pay off more per dollar owed than undergraduate students. The Association of American Medical Colleges (AAMC) estimates that, accounting for interest under the Pay As You Earn repayment program, a student with $180,000 in loan burdens could pay almost $380,000 in total repayment. During a three-year residency, the AAMC estimates that total repayment to reach nearly $450,000. This amount increases further if a student pursues a specialty care field.

Those kinds of figures may be enough to intimidate any bright student considering a career in medicine. But students in ethnic and racial minority groups that are underrepresented in medicine, and those from lower-income families, can be particularly daunted by the prospect of six-figure loan burdens. According to the most recent AAMC report, 18.2 percent of black high-school sophomores said they aspired to apply to medical school, but only 6.7 percent actually applied. For Hispanic high-school sophomores, 24.4 percent said they wanted to go to medical school but only 6.8 percent applied.

According to 2014 AAMC data, while 13 percent of the U.S. population was black, they only made up 4.1 percent of the physician workforce. Hispanics accounted for 18 percent of Americans, but only 4.4 percent of the physician workforce. This in turn likely contributes to the lack of physicians making direct efforts to serve these communities. According to research published in JAMA, despite making up less than 30 percent of the physician workforce in 2013, physicians from underserved groups are significantly more likely to see nonwhite patients, and “nonwhite physicians cared for 53.5 percent of minority and 70.4 percent of non-English-speaking patients.”

Additionally, the cost of medical school likely deters applicants from lower-income rural communities as well. This could contribute to the fact that while 20 percent of Americans live in rural areas, only 10 percent of physicians practice where people in rural communities can access them. With a shortage of about 4,000 primary care physicians, 77 percent of rural U.S. counties are designated as health professional shortage areas.

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Segregated Living Linked To Higher Blood Pressure Among Blacks

The following article by Carmen Heredia Rodriguez originally appeared on Kaiser Health News.


For African-Americans, the isolation of living in a racially segregated neighborhood may lead to an important health issue: higher blood pressure.

A study published Monday in JAMA Internal Medicine suggested blacks living in such areas experienced higher blood pressure than those living in more diverse communities. Moving to integrated areas was associated with a decrease in blood pressure, and those who permanently stayed in localities with low segregation saw their pressure fall on average nearly 6 points.

Kiarri Kershaw, assistant professor of preventive medicine at Northwestern University in Chicago and lead author of the study, said the findings reinforce the close relationship between social policy and community health outcomes.

“It lends credence to the notion that we should bring public health practitioners and health policy officials to the table to make these decisions,” she said. Researchers used data from a long-term study that has followed 2,280 African-Americans over the course of 25 years, checking in every three to seven years to track blood pressure.

Heart disease is the leading cause of death in the United States, and African-Americans are disproportionately affected by the condition. According to the American Heart Association, 46 percent of non-Hispanic black men and nearly 48 percent of non-Hispanic black women live with a form of heart disease, while about 36 percent of non-Hispanic white men and 32 percent of non-Hispanic white women do.

Georges Benjamin, executive director of the American Public Health Association, said the burden to address such disparities falls on society at large.

“It doesn’t just hurt African-Americans or people of color. This hurts everybody,” he said. “Because everyone pays not just in terms of humanity, but in terms of dollars.”

Doctors generally record two numbers for blood pressure: the diastolic pressure — the blood’s force inside the veins when the heart is at rest — and the systolic pressure, which gauges the blood’s force when the heart beats. Blood pressure is measured in millimeters of mercury, or mmHg (using mercury’s chemical element symbol), with systolic pressure reported first, such as 115 mmHg over 75 mmHg.

Researchers found residential segregation was associated with changes in systolic blood pressure, which is tied to adverse cardiovascular events, such as a heart attack. The findings did not show any changes in diastolic blood pressure.

The scientists also collected data on a variety of other social indicators including level of education, poverty and marriage status. They ranked the level of segregation in participants’ neighborhoods as “low,” “medium” and “high” based on the number of African-Americans in the larger area.

When compared to African-Americans living in highly segregated locations, participants living in medium-segregation neighborhoods recorded blood pressure that was on average 1.33 mmHg lower. Those residing in low-segregation areas were an average 1.19 mmHg lower.

Blood pressure for black residents who permanently moved into medium segregation locations decreased on average 3.94 mmHg. African-Americans who stayed in low-segregation locales saw an average decrease of 5.71 mmHg.

Read the full article.

African American Health — The latest from the CDC

The May 2017 edition of Vital Signs released by the Centers for Disease Control and Prevention (CDC) focuses on both improvements and concerns in the health of African Americans. The report states:

  • The death rate for African Americans decreased 25% from 1999 to 2015.
  • African Americans ages 18-49 are 2 times as likely to die from heart disease than whites.
  • African Americans ages 35-64 years are 50% more likely to have high blood pressure than whites.

View the May 2017 Vital Signs online.

Download a PDF.

 

The Insidiousness of Unconscious Bias in Schools

From the article by Seth Gershnson and Thomas S. Dee at Brookings:

Humans frequently make automatic decisions at a subconscious level. The human brain’s capacity for reflexive decisionmaking is what Nobel Laureate Daniel Khaneman calls “System 1” (as opposed to the more analytical, thoughtful, deliberate decision making of “System 2”) in the best-selling “Thinking, Fast and Slow.” This evolutionary adaptation was, and is, sometimes necessary for survival. However, these automatic responses occur via the rapid processing of new information through existing patterns of thought. Thus, because our automatic responses are shaped by our lived experiences and the broader social contexts in which we live and work, a pervasive byproduct of reflexive decisionmaking is unconscious bias (UB), which is also referred to as implicit bias or implicit social cognition.

Specifically, UB is the phenomenon in which stereotypes, positive or negative, influence decisions and behaviors without the individual consciously acting on the stereotype or being aware that he or she is doing so. Moreover, UB can occur even when individuals know or believe the stereotype to be false.

The insidiousness of UB is that it can create self-fulfilling prophecies that create and perpetuate inequities between in- and out-groups, even when the initial stereotype was incorrect (and there was no pre-existing difference between in- and out-group members). This post outlines some promising interventions we identify in a recent report, commissioned by Google’s Computer Science Education Research Division, that can short-circuit the recursive processes and self-fulfilling prophecies triggered by UB.

In this report, we argue that the consequences of UB may be particularly salient in the hierarchical environments of schools. Specifically, UB likely perpetuates socio-economic, gender, and racial gaps in educational outcomes such as academic performance, engagement with school, course and major choice, and persistence in higher education, particularly among historically disadvantaged and underrepresented groups such as low-income and racial-minority students. These gaps in educational outcomes then manifest in corresponding workplace disparities in pay, promotions, and employment.

Indeed, there is ample evidence of UB in educational settings, both in experimental labs and “in the field” with real individuals who were unaware of their participation in an experiment. For example, Moss-Racusin and colleagues conducted a lab experiment in which science faculty at research universities reviewed fictitious applications for a hypothetical lab assistant position and systematically rated male “applicants” higher than otherwise-identical female “applicants.” In a similar field experiment, Milkman and colleagues emailed meeting requests from fictitious prospective doctoral students to professors and found that white male “students” received more, and faster, responses than female and non-white students, particularly in higher-paying STEM careers like computer science and engineering. A recent field experiment conducted by one of us and colleagues found that the instructors of online courses were nearly twice as likely to respond to discussion-forum comments placed by students who were randomly assigned white-male names. Consistent with a UB interpretation, the pro-male bias was observed among both male and female faculty in these studies. The K-12 context is also ripe with suggestive, quasi-experimental evidence of pervasive UB in the form of systematic grading biases and student-teacher racial match effects.

Additionally, individuals from stereotyped out-groups themselves react negatively to seemingly innocuous environmental factors, such as the demographic composition of a classroom, the race or sex of an instructor or proctor, and even the design and decoration of the classroom. One example of this is the phenomenon of stereotype threat, whereby the mere threat of being stereotyped by a white (male) instructor, even when no outright bias is expressed, may distract black (female) students, ultimately leading to poor performance on exams and even disengagement from school.

Read the full article.

 

Black History Month Sheds a Light on Racism as a Public Health Threat

From the article posted by Atif Kukaswadia on the PLOS Blogs: Public Health Perspectives:

Black History Month came and went all too quickly — while it gave our nation a spotlight for the accomplishments and contributions of the black community, it also reminded us to reflect and focus on the threats facing African-Americans all year around. Beyond the month of February, civil rights advocacy continues to address racial disparities in voting rights, education and criminal justice, but discrimination also impacts the black community in ways that aren’t typically seen as social issues. This is particularly true in public health and should be addressed by doctors and nurse practitioners.

Discrimination affects mental and physical health

Racism is detrimental to mental and physical health because repeated exposure causes a heightened sense of fear and anxiety regardless of whether victims experience physical violence or merely anticipate discriminatory behavior. The Southern Poverty Law Center reported more than 1,000 hate crimes in the month following the 2016 presidential election — 221 of which were logged as anti-black incidents. The past several years of media coverage on tragic cases of police brutality and alarming stop-and-frisk regulations shows us that many more cases often go unreported, and have profound negative impact on the health of African-Americans.

Long-term physical manifestations of discrimination include depression, high blood pressure, cardiovascular disease, breast cancer and premature death. One of America’s leading social epidemiologists, Nancy Krieger, points out that constant stress from racial profiling can give way to unhealthy coping mechanisms, like over- or undereating, retreating from personal relationships, unstable anger management, violence, and other lifestyle choices. These coping mechanisms exacerbate poorer health outcomes overtime, creating a cycle based in what Krieger terms “embodied inequality” — the idea that human bodies do not partition social and biological experiences.

Discrimination shapes health care

Indirect effects of racism in health care are often harder to see on the surface, but can create barriers to accessing quality care. These barriers can be identified through social determinants of health, which are “conditions in one’s environment — where people are born, live, work, learn, play, and worship — that have a huge impact on how healthy certain individuals and communities are or are not,” according to Healthy People 2020. Victims of racism are more vulnerable to the risks of living through social determinants that make it harder to seek medical care, like inadequate transportation, low income, poor health literacy, fewer educational opportunities, underemployment, and other systemic barriers.

Black communities have historically experienced more structural barriers to health care than white communities, which not only make it harder to seek treatment, but can also lead to poor outcomes even if treatment is accessed. A 2012 study from Johns Hopkins University found that many primary care doctors hold a subconscious bias toward their black patients, which undermines any positive outcomes of a medical visit. During visits with black patients, the study revealed that doctors tended to speak slower, use less positive tones, dominate conversations and spent less time addressing social aspects of the patients’ lives. Inadequate patient-doctor consultations can result in poor health literacy, which can lead patients to wait longer before seeking care for a health issue, and ultimately creates more urgent and expensive treatments long term.

Health Literacy Can Mitigate Racial Disparities

Mitigating the detrimental effects of racism — subconscious or not — is easier said than done, but begins with providers acknowledging that biases exist and are creating health disparities. While medical providers can work to eliminate attitudes that lead to discrimination, they can also participate in public policy and on-the-ground interactions with patients. On an administrative level, providers can employ more diverse staff members, and promote medical research for racial disparities in public health, and work to expand access to quality health care to African-American patients. One potential avenue for intervention is through increased health literacy but in order to promote health literacy among African Americans, nurses, social workers, and educators must collaborate to meet patients where they are, listen to their concerns, advocate for creative solutions, and train others in professional communities to do the same.

Read the full article.

Sentinel Communities: Mobile, Alabama

The Sentinel Communities project — a part of the Robert Wood Johnson Foundation’s Culture of Health Initiative — will track health outcomes in 30 cities to understand

  • Local health care landscape
  • How challenges can be addressed in areas with different geographic and historic landscapes
  • How communities make progress or address barriers in improving population health.

The Sentinel Communities were chosen to reflect the nation’s diversity in terms of demographics, geography, and approaches to health. The following, drawn from the first report about Mobile, AL., provide some context for health issues in city.

 

  • In addition to an overall 25% poverty rate for Mobile, significant income inequality exists between black and white residents, with black households earning about half the median income as white ones.
  • While educational attainment has increased among white residents, the percentage of black residents with a bachelor’s degree or higher declined between 2010 and 2014.
  • Despite progress, Mobile residents have a lower life expectancy and higher rates of teen pregnancy, obesity, smoking, and uninsurance than the national average.
  • Even with the introduction of a new Regional Care Organization that may improve insurance coverage for residents, Mobile remains a federally designated health care shortage area.

 

See the full report for charts on indicators such as income, teen pregnancy, mortality, and educational attainment as well as some of the initiatives currently in place to address health issues.

 

Doctors’ biases mean black men don’t get the same treatment in healthcare

From the article on Medical Xpress:

A new qualitative study has shown that previous bias and fear of black men likely result in them not getting the same healthcare as white male patients.

Published by the Journal of Racial and Ethnic Health Disparities, the study by Marie Plaisime, a 2014 graduate of Drexel University’s Dornsife School of Public Health and current Howard University student, found that health providers largely perceive black male patients with bias, fear and discomfort.

These findings in “Healthcare Providers’ Formative Experiences with Race and Black Male Patients in Urban Hospital Environments” back up past quantitative studies that found that black men are less likely to receive cardiac medical procedures such as cardiac catheterizations and coronary angioplasties compared to white men presenting with identical symptoms.

Plaisime’s work on this study was conducted under Jennifer Taylor, PhD, associate professor in the Dornsife School of Public Health.

“Racial bias in healthcare is worrying because one of the higest values of medical practice is to ‘do no harm,'” Taylor said. “Whether explicit or implicit, our racial biases can direct patients to different and unequal treatments that do not make them whole. No one goes into medicine wanting this to happen, so we must look at both our personal and professional socialization to check in on how those experiences may influence our actions as caregivers.”

Participants in the study included physicians, nurses and medical students from two urban university hospitals in the United States. Interviews were conducted with them to gather qualitative data on how formative childhood, personal and professional experiences with race and black men influences interactions with male, black patients today.

Plaisime and her team found themes across the interviews that were reflective of personally-mediated racism and concluded with findings of how the perception of black males and cognitive dissonance appear to influence providers’ approaches with black male patients.

Both black and white medical providers who were interviewed described examples when black male patients were treated differently based on race.

For example, one physician noted, “I’ve had … a black patient who I think had not been offered a procedure because of either where he was economically or where he was assumed to be economically because of his race. He clearly needed to be catheterized for his presentation and it was suggested that we do medical management. I spoke with the cardiologist and as soon as we started talking, he said, ‘Oh well, of course, we’ll cath’ him.’ And so, like that, it changed… certainly have enough anecdotal experience to think that people are probably [being] treated differently based on race.”

Furthermore, white providers described experiencing a sense of fear or discomfort and discussed their lack of exposure to black males. In contrast, black providers shared their frustration with media portrayal of black men, the pressure they feel to avoid confirming negative stereotypes associated with black culture, and instances of patients discriminating against them.

Read the full article.

U.S. Cancer Mortality Rates Falling, But Some Regions Left Behind, Study Finds

From the article by NCI Staff on the National Cancer Institute’s Cancer Currents Blog:

Rates of death from cancer in the United States dropped by 20% between 1980 and 2014, according to new research from the Institute for Health Metrics and Evaluation at the University of Washington.

However, these gains were not distributed equally across the country. In 160 of the United States’ approximately 3,000 counties, cancer mortality rose substantially during the same time period.

The disparities in mortality between some counties were stark, the researchers found. In 2014, for example, the county with the highest overall cancer mortality had about 7 times as many cancer deaths per 100,000 residents as the county with the lowest overall cancer mortality.

Although disparities in cancer incidence and mortality have been well documented, Ali Mokdad, Ph.D., who led the study, said that the magnitude of the disparities seen in this study “was a surprise.”

The findings were published January 24 in JAMA.

Read the full Blog Article.

Dr. Mary Bassett: We Must ‘Name Racism’ As A Cause of Poor Health

From the speech excerpt published on The Huffington Post:

The following is excerpted from Dr. Mary Bassett’s October 2016 acceptance speech, ‘Public Health Meets the ‘Problem of the Color Line,’ for Columbia University’s Frank A. Calderone Prize in Public Health. Bassett is the commissioner of New York City’s department of health and mental hygiene.

Before Hillary secured the nomination, before many “felt the Bern,” and indeed, even before there was change we could believe in, there was a presidential candidate of several firsts running to represent a major party ticket who broke the mold in more ways than many could comprehend, let alone support. I am speaking of Shirley Chisholm.

There’s so much to learn from, but what I want to focus on today is her bold, unapologetic, and explicit commitment to naming racism. In her memoirs, she wrote: “Racism is so universal in this country, so widespread, and deep-seated, that it is invisible because it is so normal.” If you think the conversation on race in our country is just getting legs now, can you imagine a presidential candidate saying this in 1972? And still, nearly 45 years later, her analysis stands.

Congresswoman Chisholm has us consider how we lose sight of what’s right in front of us.

This is a consideration that has woven its way throughout my working life. A little over 30 years ago, Nancy Krieger and I published an article in the Monthly Review titled “The Health of Black Folk.” In it, we wrote about the normalization of poor health among black people – how the status quo of poorer health and shorter lives comes to pass as one the “facts of being black.” The following passage begins this essay:

What is it about being black that causes such miserable odds? One answer is the patently racist view that blacks are inherently more susceptible to disease, the genetic model. In contrast, environmental models depict blacks as victims of factors ranging from poor nutrition and germs to lack of education and crowded housing. Instead of blaming the victims’ genes, both liberals and conservatives blame black lifestyle choices as the source of the racial gap in health.

The “facts of being black” are not, as these models suggest, a genetically determined shade of skin color, or individual deprived living conditions, or ill-informed lifestyle choices. The facts of being black derive from the joint social relations of race and class: racism disproportionately concentrates blacks into the lower strata of the working class and further causes blacks in all class strata to be racially oppressed.

I believe we’ve come a long way since the 1980s, but I’m not sure that our analysis of racism and health, or social justice and health, has grown more sophisticated, drawn more practitioners, or explicitly influenced much policy. I can say that because I continue to find myself explaining the very same concepts I wrote about in the 80s in 2015 and 2016, most recently in an interview with Big Think and in a piece for the New England Journal of Medicine about the importance of #BlackLivesMatter.

All of this is true even when there has never been more attention given to concepts like the social determinants of health and health equity. Representative Chisholm’s insight becomes prescient in this respect, for today our analysis of equity and social determinants is ironically myopic, a limitation that keeps us from fully realizing their potential as frameworks.

Today, we can speak of health equity without invoking race at all. Those who do speak of race seldom explicitly name racism, and even in those few forays into racism, there is hardly mention of the history and the contemporary of racial oppression, or the staying power of white supremacy. This troubles me, because it doesn’t take much for invisibility – what we don’t see – to become blindness – what we can no longer see.

My goal is to convince you all that we must explicitly and unapologetically name racism in our work to protect and promote health – this requires seeing the ideology of neutral public health science for what it is and what it does. We must deepen our analysis of racial oppression, which means remembering some uncomfortable truths about our shared history. And we must act with solidarity to heal a national pathology from which none of us – not you and not me – is immune.

There are many well-meaning and well-trained public health practitioners who disagree from the outset that we must name racism. That argument will sometimes claim that the very essence of public health is about helping people, pointing to increased lifespans and decreased infectious disease outbreaks over time. Their argument will at other times claim that we don’t want to muddy the clear waters of public health with the messy politics of race, that this sort of a topic is best left to protesters, opinion editorials and campaign stump speeches. I have also heard the claim that identifying racism opens this Pandora’s Box of problems that our modest field cannot hope to address comprehensively – that identifying racism hoists too heavy a burden. Last, there are those who say that racism is not the core issue, but instead poverty. We cannot fix racism, but we can fix poverty.

Of these, I believe the most dangerous claim is the first, that our technical expertise is enough to meet the challenges of poor health, wherever they are. This mindset presumes a neutrality of public health that has never been true – it ignores the fact that public health both operates in a political context and is itself, like any science, permeated by ideology.

Much is conflated when medicine and public health attempt to fly below the radar of politics by donning the armor of scientific objectivity – guarding the faith by positing the cold logic of the scientific method. Let me start by saying that science is not all methodology – one simply cannot judge the prudence of a whole ecology of funders, research proposals, theory-building, conferences, journals, institutes, and applications by reducing all of that to the scientific method. Each of these facets is fully penetrated by the biases of human behavior, by the ideologies of our time.

Consider two examples: funding priorities of the National Institutes of Health (NIH) and the public health, medical, and criminal justice response to the current opioid crisis.

In the case of the NIH, see its most recent 2012-2013 biennial report to Congress: as my colleague Nancy Krieger has pointed out, not only did it allocate only 9 of its 441 pages to “Minority Health and Health Disparities,” but within these 441 pages, the terms “genome,” “genomic,” “genetic,” and “gene” appeared 457 times, whereas “social determinants of health” occurred only once, “discrimination” and “poverty” twice, “socioeconomic” 12 times, and “racism” not at all.

Or, with regard to the current opioid crisis – and its appropriate reframing as a public health and not criminal justice issue – how differently it would have been had the same framing been used when Nixon declared his “War on Drugs!” But of course he did not. Today, the opioid crisis is perceived as primarily affecting white populations, people who need help. No such frame of deserving victims was used, however, by Nixon. Instead, as shown in Ava DuVernay’s extraordinary new film “13th” that was a “war” that aimed to criminalize the black population and reverse the gains of the Civil Rights Movement and the War on Poverty.

We must remember that objectivity is not a synonym for neutrality. Objectivity refers to the idea that independent researchers can independently seek to test the same hypothesis and, if the hypothesized causal processes are indeed going on, they should come up with the same results if they use the same methods. However, what researchers choose to study and how they frame hypotheses determines the context in which objectivity is deployed. I urge you to consider, for example, that a great deal of unacceptable actions have taken place when objective methodology is utilized without regard for the role of science in oppression: eugenics, forced sterilization, the Tuskegee study. Often these are dismissed as bad science, or unethical science, when they too, in fact, are science.

Knowing this, we must name racism in our research proposals, in our theories, in our oral presentations and conference tracks, and even in our hypotheses. The essence of naming racism is this – how we frame a problem is inextricable from how we solve it.

Read the full excerpt.

Download the full speech.

 

Communities in Action: Pathways to Health Equity

From the blog article by the Robert Wood Johnson Foundation:

Americans today live shorter, sicker lives than people in other developed countries, and, across the nation, health varies by income, education, race and ethnicity, and geography. Warning that the United States will pay the high price in lost lives, wasted potential and squandered potential resources until these gaps are closed, a comprehensive report from the National Academies of Sciences, Engineering, and Medicine (NASEM) calls for leaders across sectors to make health equity a priority for the nation.

Why Does Health Equity Matter?

When health equity is achieved, “everyone has the opportunity to attain full health potential, and no one is disadvantaged from achieving this potential because of social position or any other socially defined circumstance,” the report says. And ensuring that opportunity is crucial not just for individuals, but also for the nation’s economic and growth prospects, for its national security and for its communities’ well-being and vibrancy.

Data show the costs of current health inequities: The report estimates that racial health disparities alone are projected to cost health insurers $337 billion between 2009 and 2018. The impact on national security is also high, with some 26 million young adults unqualified to serve in the U.S. military because of persistent health problems, or because they are poorly educated or have been convicted of a felony.

…The Cost of Inequality

  • In 2015, the percentage of low-birthweight infants in the U.S. rose for the first time in seven years.
  • Racial health disparities alone are projected to cost health insurers $337 billion between 2009 and 2018.
  • Health care spending accounted for 17.5 percent of GDP in 2014.
  • In 2014, VA-enrolled veterans accounted for 17.9 percent of suicide deaths among U.S. adults.
  • People with disabilities are more than twice as likely not to receive medical care because of cost.

Read the full article.