Some African-American organizations, such as the National Medical Association, have come out in favor of continuing to recommend mammography for African-American women 40-49 years old. They argue that because African-American women are at higher risk of dying from the disease, it’s appropriate to do massive screening of the population.

This past spring, I wrote a blog post on the detrimental effects of prostate cancer screening, and what I said then is relevant to the current debate on breast cancer screening. After discussing recent studies that show the harm caused by broad prostate cancer screening, I took up the argument that — because African Americans suffer more disproportionately from the disease — screening is appropriate in that population. “However,” I said, “some would argue that the situation is different for African-American men. The burden of this disease does not fall evenly across the population. African Americans get it more often. African Americans get it at a younger age. African Americans die from the disease in disproportionately high numbers. The problem for African-American men, this argument goes, is not overdiagnosis and overtreatment of prostate cancer, but rather its underdiagnosis and undertreatment.”

“That’s a straw-dog argument. It really highlights the fact that African Americans have poor access to health care; however, it doesn’t assess the effect of screening on African-American men. If you look at the United States, out of 100 men, 20 will develop prostate cancer in their lifetime. Of that 20, three will die from their prostate cancer. Among African-American men, five of 20 will die from their prostate cancer. Although we can’t tell our patient with prostate cancer sitting in the exam room in front of us whether he will die from the disease, it’s clear that most men with prostate cancer won’t die from it. PSA testing, therefore, leads to finding and treating clinically insignificant cancers — for both whites and African Americans.”

Overdiagnosis is not just limited to prostate cancer in men. Mammography detects breast cancer in women who would otherwise have lived their lives never knowing that they had breast cancer.

Overdiagnosis is a different problem than getting falsely positive results. As noted by the USPSTF, nearly 2,000 women need to be regularly screened over the course of 10 years to prevent one woman from dying from breast cancer. However, during that same period, 10 healthy women will be falsely identified as breast cancer patients and treated unnecessarily. These women are harmed by a false-positive mammography.

With overdiagnosis, patients are correctly told they have breast cancer and are subsequently treated; however, if they hadn’t had the mammography, they would have lived the rest of their lives unaware that they ever had breast cancer. One third of women between the ages of 40 years and 54 years who die from other causes have breast cancer found on autopsy. In countries with massive breast cancer screening programs, approximately 1 in 3 women will be diagnosed with breast cancer that, had they not been screened, would not have affected them.1

What does it mean to say that overdiagnosis of breast cancer occurs 1 in 3 women? For every 1000 women over 50 screened for breast cancer with annual mammograms for 10 years: 1 woman will avoid dying from breast cancer; 2 to 10 women will be overdiagnosed and unnecessarily treated; 10 to 15 women will find out they have breast cancer but it won’t affect their disease course; and 100 to 500 women will have at least one false-positive finding, with about half of these women receiving biopsies.

As with prostate cancer screening in men, the most prudent thing for clinicians to do is to help our female patients make an informed medical choice regarding breast cancer screening. We should give them the facts regarding the modest benefit of breast cancer screening today versus the harm of overdiagnosis and overtreatment of this disease and let our patients make the choice to be screened or not. This approach is as true for African-American women as it is for others.

1. Welch HG. Overdiagnosis and mammography screening. BMJ 2009;339:b1425)

Gregory calculated standardized mortality ratios for all census districts for both periods. He used the Carstairs Index, a measure of deprivation, to compare deprivation in these districts in the early 1900s and 2001. He had data on 614 districts and was able to calculate correlation statistics between the deprivation scores and SMRs in the 1900s and 2001.

What did he find? No significant difference in the relationship between deprivation and death between the start and the finish of the 20th Century. At the start of the 21st Century, populations with the highest deprivation scores — working people and oppressed minorities — have the highest death rates. It’s the same pattern that obtained at the beginning of the 20th Century.

Western medicine and health care delivery has changed dramatically over the course of the last century. Huge social, economic, and political changes also have taken place. Yet, one essential fact remains: social inequity continues to exist, and this social inequity is the root cause of health inequities like the increased death rates among working people and racial and ethnic minorities.

(1) Ian N Gregory
Comparisons between geographies of mortality and deprivation from the 1900s and 2001: spatial analysis of census and mortality statistics
BMJ 2009;339:b3454, doi: 10.1136/bmj.b3454 (Published 10 September 2009)

Nancy Pelosi and other Democratic leaders announce their health legislation this past summer.

This morning, the pundits are hailing last night’s passage of the “Affordable Health Care for America Act” (see http://tinyurl.com/qyajn9 for summary) by the U.S. House of Representatives. However, the House health care bill marks no great advance toward providing quality health care services to working people in this country.

The legislation, if enacted, mandates individuals to purchase insurance. This provision will create millions of new customers for the insurance industry and generate billions of dollars in profits. (http://tinyurl.com/lyrj3q) Individuals and small employers will purchase insurance through a “health insurance exchange,” in which some insurance companies will participate and the government will provide a public insurance option. Individuals may qualify for a government subsidy to help pay their insurance premiums, and Medicaid will be expanded to cover more people. Some small employers will be allowed to opt out of providing health insurance plans to their employees, and others will be eligible for a government subsidy.

The mandate requiring individuals to purchase health insurance will be a hardship for many. The government subsidies will be adjusted so that individuals will pay anywhere from 1.5% to 12% of their income as health insurance premiums. The penalty for not purchasing health insurance is that you must then pay 2.5% of your income into the plan. Those under age 65 with annual incomes below $18,700 for a couple or $9,350 for an individual will be exempted from the mandate, which means (in today’s economy) millions will be uncovered by this insurance plan. As the lowest-paid workers, African Americans and Latinos will be the hardest hit by these provisions. Undocumented workers, who disproportionately lack health insurance, would be denied access to the so-called public option in this plan, and they would be ineligible for subsidies to pay for private health insurance.

The supposed benefits of the legislation are meager at best. Millions of people will remain uninsured. The touted reform to eliminate pre-existing health conditions as an excuse to deny health insurance coverage provides insurance for these people; however, it requires those with chronic health problems to pay higher premiums. The bill calls for developing a “high-risk” pool of those with pre-existing medical conditions, whose premiums will be set at 125% of the prevailing rate. The so-called public option calls for a government insurance plan that would compete with all private insurance companies in the exchange. The public plan will pay providers at least the Medicare rates; however, providers may opt out of the plan.

So, this health insurance reform bill will leave millions still uninsured, exact huge cuts on individual workers’ incomes through mandatory insurance premiums, generate huge profits for the insurance industry through enrollment of millions of new customers and higher premiums for “high-risk” clients, deny coverage to undocumented workers, and continue to deny federal money to women seeking to exercise their legal right to an abortion.

What’s to celebrate? As I see it, it’s no exaggeration to say that this bill condemns tens of thousands of people — disproportionately Black and Latino — to death. Rather than a sweeping reform of the U.S. health care system, it’s a reform of health insurance that funnels billions of dollars into that industry while leaving millions of working people with inadequate or no insurance.

What would happen if African Americans, Latinos, and Asian Americans had the same health outcomes as whites? Not only would we be spared the pain and suffering of the unequal burden of disease we bear, but we’d save billions of dollars each year.

In a recent study published by the Joint Center for Political and Economic Studies, Thomas LaVeist et al estimate that the combined costs of health inequalities and premature death in the United States between 2003 and 2006 were $1.24 trillion. Direct medical care expenditures during this 4-year period could have been reduced by $229.4 billion if racial and ethnic health inequities had been eliminated.

LaVeist and his colleagues used data from the Medical Expenditure Panel Survey (MEPS)[1] for the years 2002-2006 to develop a model to estimate health care costs for African Americans, Latinos, Asian Americans, and whites. They then re-estimated the model, assuming that each racial and ethnic category had the same health status — and, therefore, the same health care expenditures as that of the group with the best health status (usually the whites). The difference in two models represents the potential direct medical savings if all racial and ethnic groups had equal health status and outcomes. The savings in direct medical care costs totaled $229.4 billion.

To estimate the savings in indirect costs, these researchers used the MEPS data to estimate the days of work lost by adults owing to disability or illness. Then, they re-estimated the days of work lost with the racial and ethnic health inequities eliminated. The total savings came to $50.3 billion.

The researchers also estimated the costs secondary to premature death. Using data from the National Vital Statistics Reports,[2] they estimated the number of deaths by racial and ethnic category. Then, they estimated the number of deaths by racial and ethnic category if each category had the same health status as whites. This calculation gave them the number of excess deaths owing to racial health disparities. They used a very conservative estimate of $50,000 for each year of life lost to estimate the costs of premature death secondary to racial and ethnic health inequities, which was $957.5 billion.

You’d think that saving $1.24 trillion in health care costs would be important; however, no serious moves are being made to eliminate the health inequities responsible for these costs. Why don’t these excess costs motivate those who run the U.S. health care to do something to eliminate racial and ethnic health inequities?

Well, who bears these costs? Direct medical expenditures come out of the pockets of the patients, third-party payers, and some employers. LaVeist et al estimate that African Americans, Latinos, and Asian Americans paid nearly 31% of the excess direct medical costs out of our own pockets. While we consider that a loss, the barons of the health care industry consider that revenue. Excess costs for us equal profits for them.

What about the indirect costs of health inequities? Surely, they care about lost days of work? Employers tend to be very provincial in their thinking. They care about their employees’ missed days of work; however, if a worker at another shop misses work, that’s his or her employers’ problem.

Besides, 95% of the indirect costs of health inequities ($957.5 billion) were owing to the costs of premature deaths. From the perspective of employers as a class, African-American, Latino, and Asian-American workers are expendable. They can be easily replaced with others.

Those of us concerned with the premature loss of life, increased burden of disease, and increased health care costs endured by African Americans, Latinos, Asian Americans, and working people in general need to stand up and demand social justice. It’s the necessary precondition for eliminating racial and ethnic health inequity.

[1] Cohen JW, Monheit AC, Beauregard KM, et al. 1996/1997. “The Medical Expenditure Panel Survey: A National Health Information Resource.” Inquiry 33:373-389

[2] Heron MP, Hoyert DL, Murphy SL, et al. 2009. “Deaths: Final Data for 2006.” National Vital Statistics Reports 57(14). Hyattsville, MD: National Center for Health Statistics.

Last night, President Obama spoke for 45-minutes before the entire Congress and the country, cajoling us to support his proposed health insurance plan. Claiming to give us the details regarding his insurance plan, President Obama outlined points already known about his proposal. In a surprise to some, he continued to voice support for a so-called public option.

The President proposes an insurance exchange or pool to which employers and other payers would go and shop among competing health insurance providers. Insurance companies would have new restrictions placed upon them. They would not be allowed to deny coverage to people with “pre-existing health conditions,” nor would they be allowed to drop anyone’s coverage once they get sick. In some of the health insurance plans being discussed on Capitol Hill, there would be a cap placed on customers’ out-of-pocket medical costs.

I’m all for being treated more favorably by the insurance companies. However, being treated more favorably doesn’t mean that one is being treated fairly or equally.

The insurance industry has agreed to the proposed new restrictions on them not out of the goodness of their hearts. Rather, they do so because they will make billions of dollars in new profits. The proposed health insurance plans being discussed in Congress and pushed by the White House would be a boondoggle for the insurance industry. They would get millions of new customers because of the proposal to force people to buy health insurance. The federal government will provide subsidies to help people buy this insurance, thus transferring billions of dollars from the federal government into the coffers of the private insurers.

For those people who can’t get or can’t afford health insurance through an employer, President Obama proposes a public insurance option. Most people wouldn’t have access to this public health insurance. As President Obama noted in his speech, “I have no interest in putting the insurance companies out of business.” Too bad.

Instead, President Obama’s plan calls for  “making a not-for-profit public option available in the insurance exchange.” He was quick to add, ” Let me be clear – it would only be an option for those who don’t have insurance.” At most, it would be available for only about 5% of the country’s population.

The result will be that millions of people will remain uninsured. Undocumented workers are expressly excluded from coverage under the public option. “There are also those who claim that our reform effort will insure illegal immigrants,” said Obama. “This, too, is false – the reforms I’m proposing would not apply to those who are here illegally.” Millions of workers will suffer as a result of this refusal to provide health care. Thousands will die.

The so-called health care reform being bandied about in Congress amounts to some tweaking of health care insurance and is designed to ensure the continued profits of the insurance, pharmaceutical, and health care industries. The health care industry is all about making profit, not providing health care. Let’s take the profit out of it. Let’s revolutionize health care by providing it to everyone through a nationalized, government-run health care system.

According to the United States-Mexico Border Health Commission, there are some 12 million people living in the 32 border counties on the U.S.-Mexico border, running from San Diego County, California to Cameron County, Texas. Latinos comprise a little more than 52% of the population in this region. Three of the ten poorest counties in the United States are located in the border area, and twenty-one of these counties have been designated as economically distressed areas. Meanwhile, two of the ten fastest-growing metropolitan areas in the country — Laredo and McAllen — are located on the Texas-Mexico border. (McAllen recently made headlines when a study found it to be the most expensive health care market in the United States.)

High rates of unemployment and under-employment, high poverty rates, and lack of health care insurance underlie the huge disparities in the health status of this population. Will the AMA commission step up to the plate and demand health insurance coverage for everyone in the border counties? I doubt it. They likely will rail against the deplorable health conditions along the border; yet, speak out against providing health insurance for undocumented workers — so-called illegal immigrants.

Health care is a human right, and all people — documented and undocumented — deserve it. We can’t begin to seriously address health disparities along the border without providing access to health care to undocumented workers.

Hurricane's victims seek shelter in Superdome

This Saturday marks the fourth anniversary of the day Hurricane Katrina slammed into the Gulf Coast. The people of New Orleans, particularly the poor and African-American communities, suffered disproportionately from the hurricane’s effects, living in the least-protected areas and lacking the resources to flee the storm’s onslaught. The lackadaisical response of the federal, state, and local governments to the necessity of robust rescue efforts compounded the hurricane’s damage.

The health status of people in Louisiana — one of the least healthy states in the country prior to Hurricane Katrina — has deteriorated even more over the last 4 years. Pre-Katrina, approximately 21% (900,000 individuals) of Louisiana residents were without health coverage. In New Orleans, individuals without health coverage typically received care at either Charity Hospital or University Hospital, which are a part of the Louisiana State University health system.

In 2004, approximately 75% of patients treated at Charity Hospital were African American and approximately 85% had an annual income of less than $20,000. (The federal poverty rate is $22,000 a year for a family of four.) Charity Hospital also was the area’s primary provider of substance abuse treatment, psychiatric care, and HIV/AIDS treatment. Pre-Katrina, Charity Hospital was faced with limited financial capacity, due in part to budget cutbacks by local governments and a high percentage of uncompensated care.

The weakened Charity Hospital was finished off by Katrina. Its doors remain closed today, and a hospital that was once a safety net for Blacks, poor, and uninsured patients is now an empty building surrounded by wire fence.

Not that health problems in New Orleans have abated. According to The Economist of May 16, 2009, some two-thirds of New Orleans residents report having a chronic health problem, which is a 46% rise since 2006. Mental health issues are a particular problem. The percentage of people with depression has tripled since 2006, and the suicide rate has doubled since 2005.

While the federal government has poured more than a trillion dollars into the coffers of the banks, insurance companies like AIG, and the auto industry, only about $400 million federal dollars have been directed specifically towards restoring health services, including mental health initiatives, in New Orleans. The most commonly noted barrier to providing mental health services is a lack of mental health providers, and the most commonly cited barriers to receiving mental health care for children include a lack of transportation and competing family priorities (including housing, employment, and other financial concerns).

Almost a fifth of New Orleans households live below the federal poverty line. Less than half of New Orleans’s public transport facilities have been restored. Some 12,000 people are still homeless.

What New Orleans, and the other communities hit by Hurricane Katrina, needs is a massive public works program to rebuild transportation, housing, schools, and the health care system. The paltry effort being mounted by the federal government and a few foundations is a band-aid on a festering wound that needs radical treatment. The lives of tens of thousands depend upon such action. We need to demand that the federal government provide massive relief. The poor and minority communities of the Gulf Coast deserve it far more than the Wall Street financiers.

Nowhere is this fact more clear than among workers and working farmers in rural America. Take the coalfields of far southwestern Virginia, for example. Whereas the death rate in the state is 780/100,000, the rate in southwestern Virginia is more than 1,200/100,000. About 203/100,000 Virginians die of heart disease each year compared with about 340/100,000 in the Virginia coalfields. It’s the same with cancer deaths: statewide, 185/100,000 people die from solid tumor cancers; whereas in the state’s southwestern coalfields, some 260/100,000 die from those cancers.

The psychological distress and dis-ease of this population is also high. Virginia’s overall suicide rate is 11/100,000, whereas in the coalfields it’s double at 22/100,000. Substance abuse, particularly prescription drug addiction, is rampant in southwestern Virginia, which takes its toll in human suffering and death. Fatal drug overdoses in the state occur at a rate of 8/100,000; however, in far southwestern Virginia, the rate is 40/100,000.

As noted in earlier posts, social inequities underlie these health inequities. Nearly 10% of Virginians live below the federal poverty line; 20% of people in Virginia’s coalfields live below this poverty line. The per capita income of people in far southwestern Virginia is about 58% of the per capita income of the state’s population.

Working people in the coalfields of Virginia lack access to health care — both because of a scarcity of available physicians and health care facilities and owing to the high number of people lacking health insurance. Some 20% of people in southwestern Virginia are uninsured compared with about 13% statewide.

Until these social inequities are resolved, health inequities will continue to plague the coalfields of southwestern Virginia and the rest of rural America. A national, single-payer health plan would go a long way toward decreasing the disparities.

(Statistics on southwestern Virginia obtained from the Healthy Appalachia Institute. www.healthyappalachia.org)

Percent of people uninsured (Family Core, NHIS 2008)

The health care reform package being crafted by the U.S. Congress and President Obama will deny insurance coverage for millions of immigrant workers. The August 11th Chicago Tribune reports that House Speaker Nancy Pelosi “emphasized that illegal immigrants would not be covered under the current proposals.” Workers, including those without legal documentation, have no voice in the U.S. Congress. The same Tribune article notes that the Congressional Hispanic Caucus has called for insurance coverage “only for ‘legal, law-abiding’ immigrants who pay their ‘fair share’ for health care.”

One in three Latinos and one in five African Americans lack insurance, compared with one in eight whites. (See graph.) This situation is getting worse in the current economic crisis. Blacks and Latinos are the last to be hired and the first to be fired. As unemployment among African Americans and Latinos increases, so too will the number of uninsured or underinsured in those populations.

Health care is a human right. Undocumented workers deserve health care. This is not just a moral issue; it’s a matter of life and death. Those who lack health insurance lack access to health care. As a result they are sicker, die younger, and die in disproportionately higher numbers than those who do have insurance. This health inequity falls upon working-class and minority populations.

President Obama and the Congress are cobbling together a health care plan that will kill hundreds of thousands of Latino workers. It’s a crime, and we need to speak out against it.

Physicians racial biases affect their clinical decision-making. In a landmark study by Schulman et al, African-American patients were less likely than whites to receive life-saving therapy for a heart attack — although everything about the patients’ presentation was the same except for the color of their skin. Schulman argued that racial bias against African Americans must be the reason for the disparity in the proposed therapy. Schulman’s finding has been replicated numerous times in the last 10 years. Each time, the researchers find that presumed racial bias affects the physicians’ clinic decisions, resulting in poorer quality care for African Americans. Each time, however, the researchers make no objective measurement of the racial bias.

In 2007, this changed. A study conducted by Green et al replicated the Schulman findings, showing that a group of emergency medicine and internal medicine physicians were more likely to recommend life-saving medical therapy for heart attack patients if they were white. However, Green et al used a psychometric instrument called the implicit association test (IAT) to measure unconscious racial bias in their study subjects. They objectively demonstrated that racial bias was associated with the preferential treatment of the white patients.

The Web-based IAT is a well validated tool that has been used in more than 400 studies and in more than 10 million subjects. Go to the Project Implicit website and check it out yourself.

Brian Nosek, PhD, an Associate Professor in the Department of Psychology at the University of Virginia and the Director of Project Implicit, and colleagues have a paper in the upcoming August 2009 issue of the Journal of Health Care for the Poor and Underserved that evaluates the unconscious racial biases of physicians.

When I asked Dr. Nosek about physicians’ racial biases, he noted that “Implicit biases are pervasive and have been linked to important behaviors, including treatment decisions by health care providers.” In discussing his recent study in the Journal of Health Care for the Poor and Underserved, Nosek said “we found that – in terms of implicit racial biases – medical doctors are much like the rest of us.  We measured more than 2,500 MDs and their implicit preference for White people over Black people was similar in magnitude to JDs, PhDs, and people without advanced degrees.”