New Volume Investigates Bias and Disparities Based on Race and Class in US Health Care
Between
1964 and 1968, W. Michael Byrd was training to be a physician at Meharry
Medical College in Nashville, Tennessee when he noticed a grim pattern
of treatment behavior: African Americans and poor whites were regularly
offered different standards of care than their wealthier white counterparts.
Byrd wondered why. In his free time, he began to painstakingly collect
variegated data about biased clinical decisions and health system dysfunction
based on race and social class. In the mid-1980s, he met Linda Clayton,
an assistant professor at Meharry, and the pair began laying the foundation
for a book. In 1991, they came as MPH students to HSPH, where they later
received fellowships that allowed them to begin formally writing the book.
Now, they are married and are both senior research scientists at the Division
of Public Health Practice. They are authors of a sweeping two-volume set
on the experiences of African Americans and disadvantaged patients in
Western health care systems. Volume One, An American Health Dilemma:
A Medical History of African Americans and the Problem of Race--Beginnings
to 1900, hit bookstores last week.
Byrd and Clayton sat down with ATS to tell their personal stories as African Americans growing up in the segregated South, as medical practitioners treating disadvantaged and advantaged patients, and as chroniclers of the history of Western health care in conflict about issues of race and class. . .
ATS: Dr. Byrd, when you were a medical student in Nashville in the 1960s, you treated African-American and poor white patients at an underfunded hospital that generally served blacks. White doctors from a wealthy medical school often served as attending physicians for your patients. What did you notice about the treatment practices?
Byrd: I saw huge dichotomies according to race and class in the way patients were managed by white doctors. Often the black or poor patients were managed in a manner that was not in their best interests. I would see black and poor white patients come into the emergency room after being rejected from the hospitals that catered to wealthier white patients. The reasons given would be along the lines of they didn't have any "colored beds," and sometimes, no reason would be given.
ATS: Do you think the rejections were based on race or money or both?
Byrd: Both.
ATS: So you began researching the prevalence of the differences in health care standards according to race and class.
Byrd: The differences not only had clinical implications but also ethical and moral ones. I started to wonder what made these highly educated, cognitive men suspend their objectivity and choose these biased decisions based on a person's race or class or both. As a medical student, one expects the medical profession to operate on a higher plane. Witnessing doctors abrogating the objectivity of medical textbooks and the Hippocratic Oath, I could have become disillusioned. Instead, I got curious.
Clayton: My experience had been different. I trained at Duke, which was an elite school in North Carolina, and most of my patients were white, so I didn't see many overt discrepancies. At Meharry, Michael and I began discussing these problems, which heightened my awareness and understanding of the issues of race and class in American medicine.
ATS: When you started writing, did you plan to cover the entire history of African Americans in the health system relative to race and class?
Byrd: Yes, we did. One can't really understand all of the basic assumptions driving the race and class problems in the health system unless they have this background.
ATS: You make a point of placing the development of biases within the context of historical events.
Clayton: Our research has shown that the health care experience of African Americans has paralleled their citizenship status. From the beginning to the Civil War, African Americans were in a "slave health subsystem" with poor health status and outcomes. During the period from 1865 to 1965, African Americans were trapped in a segregated, inferior tier of a larger, mainstream system. That tier began to be dismantled after Medicare and Medicaid were passed and hospitals were desegregated in the late 1960s. However, large blocs of the multi-tiered, unequal system remain today.
Byrd: The health parameters for African Americans improved dramatically from 1965 to 1975. Then retrenchment started under the Carter administration. Funding was cut during the Reagan-Bush era, which was one of the most regressive periods in health care for African Americans and poor people. That's one reason we're still saddled with disparities.
ATS: You describe the exploitation of African Americans and other disadvantaged groups for medical purposes. What did you find?
Clayton: There has been a tradition of exploitation, abuse, and misuse of blacks and the poor in the health system. Tuskeegee was only the tip of the iceberg.
Byrd: The first documentation of exploitation for medical purposes that we could find was in Alexandria after Alexander the Great. Vivisection was being performed on living prisoners, cutting open their abdomens when they were still alive. This was the first stage of a Western tradition of exploitation.
Clayton: The American situation was unique because of slavery. Surgeons and researchers had a captive population on which to operate and experiment.
Byrd: Doctors in continental Europe became aware of this. They rationalized that the great advances in surgery being made at the time by American doctors resulted from the Americans' ability to operate on slaves. The Europeans said, "They can perform untried, experimental surgeries we wouldn't dare do."
ATS: The exploitation continued into the 20th century?
Clayton: Yes. Many examples could be given, but one is the use of HeLa cells by many laboratories throughout the world. These cells were taken from cancer tissue of an indigent African American patient named Henrietta Lacks at a major academic health center in the 1950s. They were used without her consent and against her family's wishes.
ATS: What are some of the lessons of this book?
Byrd: Health status, outcome, and service indicators in which one could find hundreds of disparities based on race and class didn't occur by accident. They were not spontaneous. They were systematic.
Clayton: If health disparities are to be eliminated, there must be systemic change. People must not be seen or treated on the basis of their skin color or class. There must be changes at philosophical, policy, institutional, and individual levels.
ATS: Is that possible?
Clayton: It's possible but not likely to happen in the near future. It will require a medical system that views everyone as having a right to equal access to high quality health care.
Byrd: It will also require elimination of bias and tiering of the health system.
Volume Two, An
American Health Dilemma: Race, Medicine, and Health Care in the United
States--From 1900 to the Dawn of the New Millennium, is scheduled
for release in September, 2001. The set is published by Routledge.
