Thursday, June 12, 2008

From the Hill

Two days ago I went to a congressional hearing of the House Committee on Ways and Means health subcommittee. The topic of the hearing was "Addressing Disparities in Health and Healthcare: Issues for Reform." Four Congresspeople and a panel of physicians and public health experts testified on the various disparities. Three Congresswomen (yay for women in government!)were members of the TriCaucus, that is, the Congressional Black Caucus, the Congressional Hispanic Caucus, and the Congressional Asian Pacific American Caucus. When I think of health disparities, the most common groups that are affected are racial and ethnic minorities. But Congressman Jerry Moran of the 1st Kansas district brought to the committee a disparity I hadn't thought much about, the needs of the rural community. It was pretty cool just to be at a congressional hearing. It was in the Longworth building, which is the office building where some Reps have their offices. Saw lots of staffers, interns walking around.

So I want to make a connection from this hearing to two more articles I read yesterday. The first, "Doctors Miss Cultural Needs, Study Says" is an illustration of the disparity in health outcome. By this I mean that people of difference racial and ethnic groups have access to the same physician or same pool of physicians so the ability of the physician is the same for all people. This was a measure of outcome because it looked at three factors that measure how well diabetes is controlled: LDL cholesterol, blood pressure, and hemoglobin A1C, a stabler, more long-term measure of blood glucose. Given the same physicians AND adjusting for socioeconomic factors AND clinical differences in patient conditions, the study showed that African-Americans had poorer control of their diabetes.

This isn't to say that doctors are necessarily racist but that they need to talk to patients in ways that are tailored to their habits and culture. For example, if a doctor recommends a certain diet that is wholly unfamiliar to people of that culture, then there will be poor compliance. (See previous entry regarding dietary habits.)

There are also disparities in quality of care, which includes barriers such as lack of language interpreters so that patients don't understand their diagnoses, prescription directions, and don't use preventative care. Furthermore, disparities in access of coverage also exist. That is, minorities are also more likely to be poor and therefore don't have private insurance. Even within an insurance plan, there are disparities.

One way to have more culturally competent care is to have more minority doctors! According to testimony by Dr. Mohammad Akhter of the National Medical Association, blacks, Hispanics, and Native Americans made up only 6% of US medical school graduates. (I guess Asians are overrepresented?)

Of course doctors can be taught about minority communities, but really, physicians who aren't old white men don't feel as comfortable talking to old white male physicians either. People who grew up in rural areas are more likely to return there to practice because frankly, if you didn't grew up in NYC, you'd think agricultural Kansas is inhospitable. MSU's College of Human Medicine should be praised for its rural medicine program. It trains med school students to practice in rural communities.

From health and healthcare, we go to another issue faced by a particular minority: Asian Americans. "Report Takes Aim at ‘Model Minority’ Stereotype of Asian-American Students" describes how this stereotype is not true because Asian Pacific American is such a broad category that it encompasses a very diverse group of people, from native Hawaiians to Chinese to Sri Lankans. If we look at the APA group by nation, then stark differences appear, "while most of the nation’s Hmong and Cambodian adults have never finished high school, most Pakistanis and Indians have at least a bachelor’s degree."

I want to emphasis this point: The SAT scores of Asian-Americans, it said, like those of other Americans, tend to correlate with the income and educational level of their parents.

The expansiveness of the category APA is another issue discussed at the hearing. There are dozens of countries included in the category APA and hundreds of languages. Timely and disaggregated data is needed to identify their needs and try to create policies that help them. This is a particularly appalling example: The Social Security Agency does not ask the race of its applicants for SS cards. Why is this important? Because many Medicare stats use SSA data.
The sheer number of languages spoken by APA patients makes it difficult for doctors and hospitals to provide translators for them. Unlike Hispanics who mostly speak Spanish, no one language unifies APA.

Data is powerful but data is precisely what is lacking about APA. The statistics in this article really surprised me and they are a potent force dispelling the model minority myth. I was surprised by some of the stats. For example, a larger percent of Asian Americans earned degrees in the humanities and social sciences than all students! The numbers are the same for biological/life sciences. (But they do earn more engineering degrees.)

The implications of disaggregated data are huge: we will be able to help APA patients get medical care that is tailored to their culture, not just that half of the world. Hawaii to Central Asia is a large area! We'll also be able to help APA students who are struggling in school.

Committee on Ways and Means
Hearing: Addressing Disparities in Health and Healthcare: Issues for Reform (with links to individual testimony)
Congressional Black Caucus
Congressional Hispanic Caucus
Congressional Asian Pacific American Caucus
Jerry Moran Kansas 1st District
Doctors Miss Cultural Needs, Study Says
Report Takes Aim at ‘Model Minority’ Stereotype of Asian-American Students

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