Legacy of discrimination reflected in health inequality

Risk factors that can lead to heart disease and stroke include obesity, diabetes and high blood pressure. For African Americans, another issue also threatens their cardiovascular health: discrimination.

"This is an uncomfortable subject for many people," said Dr. Keith Churchwell, executive vice president and chief operating officer at Yale New Haven Hospital in Connecticut. "Most of us want to think about health care as a monolithic bloc where everyone has the opportunity for equal access to care and there's really not a difference. There is."

One jarring number illustrates the gap. As of 2017, the average life expectancy at birth was 78.8 years for white people and 75.3 years for their black peers, a difference of 3.5 years, according to the latest available data from the Centers for Disease Control and Prevention.

Contributing to the gap are higher rates of hypertension, obesity and diabetes among African Americans, along with social and environmental factors such as unequal access to healthy food and safe spaces for physical activity.

"All of that leads to a persistent imbalance and uneven playing field for the treatment of and the outcomes for cardiovascular disease between our different communities," Churchwell said. "It is a health issue, a scientific issue and a public policy issue that we have to talk about and confront."

The challenge isn't new. A landmark 1985 report by Health and Human Services Secretary Margaret Heckler called the disparities in health outcomes between black and white people "an affront both to our ideals and to the ongoing genius of American medicine."

A 2003 report from the Institute of Medicine, now known as the National Academy of Medicine, cited "historic patterns of legalized segregation and discrimination" that still resulted in African Americans being less likely to receive appropriate heart medication and bypass surgery, while also receiving lower-quality basic clinical services. It recommended, among other things, better cross-cultural education and training for health professionals and more community outreach to ensure people are empowered to take charge of their health care.

Last year, the American Academy of Pediatrics weighed in with a policy statement. It called on pediatricians to combat racism with strategies to deliver quality care to diverse populations and to advocate for reducing disparities in their communities.

"Racism is harmful to health and particularly cardiovascular health," said Dr. Danielle Dooley, a pediatrician at Children's National Hospital in Washington, D.C., and co-author of the policy statement. "There's a large body of literature that shows people who are exposed to racism in childhood are more likely to have cardiovascular events later in life."

Dooley, who is medical director of community affairs and population health at the hospital, said the impact of stress, whether through bullying, discrimination or difficult living conditions, is often underestimated as a health hazard. That should motivate doctors to advocate for change beyond their offices and clinics.

"There are many ways that pediatricians can advocate on the community level to deal with structural barriers as well," she said. "We have a really important role to play in building more just and equitable communities that ultimately improves everyone's long-term health."

Are all these good intentions making a difference?

"I think it's always a first step to recognize and acknowledge the issue," Dooley said. "That's how you make progress. If we were ignoring it, I would not be optimistic."

Churchwell agreed.

"In the past generation, we have definitely seen progress," he said. "There is some innovative work that's been done in reaching out to these communities, and I see young academics and clinicians who are actively engaged in bringing solutions to this problem."

For example, that 3.5-year gap in life spans between black and white residents in the U.S. is actually smaller than when it was 5.5 years in 2000.

"We still see a persistent difference that tells us there's work to do," Churchwell said. "I think it's extremely important that we're continuing to talk about this, and it stays on the front burner."

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