In more than 700 pages, a 2002 report published by a committee of the Institute of Medicine (now the National Academy of Medicine) delivered a blistering indictment of the medical racism experienced by Black and brown people throughout the country. The report also offered policy recommendations to address the problem.
It is disheartening to realize that, after almost two decades, little has changed.
Revealing “Unequal Treatment”
“Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care” was the first report of its scope and magnitude to call out systemic racism as one of the leading factors behind deep-rooted disparities in American healthcare. The Institute of Medicine, an independent government advisory organization, produced evidence from research by its blue-ribbon committee experts, with the goal of igniting a long-overdue conversation that would result in measurable change.
Although earlier reports, such as one dating from 1999 and issued by the National Cancer Policy Board, had called attention to the issue, “Unequal Treatment” represented a sea change in policy research. No other work had covered such a broad scope of medical conditions, or provided as much comprehensive analysis.
“Unequal Treatment” contained a number of strong recommendations designed to make the healthcare experience better for both patients and medical professionals. It pointed to ways to improve funding and allocation of care, data management, community healthcare systems, language interpretation services, cross-cultural training for providers, and more.
The ultimate goal was to assist policy-makers and other decision-makers in building systems of equity and inclusion that would give every American—regardless of race, ethnicity, or social background—equitable access to quality healthcare.
While previous studies had kept their focus simply on access to healthcare, “Unequal Treatment” reported that, even when patients of different backgrounds had comparable access to healthcare services, the treatment they received was not comparable. These findings held true even when controlling for factors like income and insurance.
“Unequal Treatment” also zeroed in on the “clinical encounter”—the provider-patient relationship—to see how interactions at that level can impact wider disparities. As we have since learned, the attitudes and expectations of doctors and medical teams play a big role in the quality of care that patients receive.
At the time of its release in the early 2000s, the report sent, in the words of the editorial team at StatNews, “shock waves through medicine.” One prominent physician and advocate who served on the report’s committee called the published results a “wake-up call” for anyone working in patient care. The chair of the “Unequal Treatment” committee said that the “bias, stereotyping, prejudice, and clinical uncertainty” found within medical teams may play a significant role in creating and sustaining disparities in healthcare.
At the time, newspapers gave front-page coverage to stories outlining the report’s findings, and members of Congress formed committees to hold hearings on the problem. Referring to what she’d learned from the report, Donna Marie Christensen, a doctor who served in Congress as a non-voting delegate representing the U.S. Virgin Islands from 1997 to 2015, said that Black and brown citizens refused to be “sick and tired anymore.”
One especially disturbing finding was that Black women diagnosed with breast cancer were less likely than their white counterparts to receive radiation therapy paired with mastectomy and post-mastectomy rehabilitation support. In addition, two times as many Black men as white men received no treatment whatsoever for prostate cancer. Black patients overall were 60 percent more likely than white patients to not receive any treatment for pain associated with cancer.
Problems of the present
In summarizing the amount of progress made in the 20 years since the publication of “Unequal Treatment,” StatNews noted that multiple inequities and disparities persist.
Black and brown Americans in 2022 continue to experience poorer health outcomes in terms of almost every disease and condition examined in the original report. Black and brown people die at higher rates from these conditions.
Although the racial life expectancy gap has been closing over recent decades, white Americans in 2018 still lived an average of 3.6 years longer than their Black counterparts. In 2019, the Centers for Disease Control and Prevention estimated that approximately 200 Black Americans daily were suffering premature deaths. Many of these deaths stemmed from causes like cardiovascular disease and other conditions for which better treatment would have improved the patient’s length and quality of life.
It gets worse when you look at the statistics during the COVID-19 pandemic, with Black and brown people making up disproportionate numbers among the lower-wage, front-line essential service workers most at risk. Current studies have found that Black American life expectancy has dropped again and now stands at five years shorter than that of white Americans.
Imagine having five years stolen from your life. That’s five years less to be with your family and friends, five years less to achieve your goals. This is unconscionable.
No easy answers
It’s deeply disturbing that so few of the more than 20 detailed and policy-focused recommendations from that landmark 20-year-old report were acted upon. Where can we go from here?
Data collection that would allow us to precisely quantify and track disparities is still, in the words of one expert, “a mess.” That’s something we can improve. Recruiting and retaining larger numbers of culturally competent healthcare professionals who look like—and understand—the communities they serve will also go a long way toward improving communication and building trust.
With the greater awareness today of the damage structural racism inflicts, we need to make the recommendations from “Unequal Treatment” a national, not just a local, priority. The big obstacle here is that the American healthcare system isn’t a national one. It is fragmented. Healthcare administration sprawls across federal, state, and local agencies, as well as the enormous variety of administrations among private provider networks.
In addition, providers, administrators, and the public must acknowledge the tangible effects of structural racism, as well as implicit bias on the part of individual medical professionals. This is far easier said than done, but failure to confront the issue simply ensures that more Black and brown Americans will lose more quality years with the people they love.