A review article in the January issue of Journal of the American Geriatrics Society paints a bleak picture of end-of-life care for Hispanics and blacks.
"Health disparities correlate closely with socioeconomic status. It's true at every stage of life," says Barbara Krimgold, director of the Scholars in Health Disparities program at the Center for the Advancement for Health. "In addition, race is inextricably intertwined with economic status but has an additional impact on health status, such that at every income level blacks have worse health and health care than their white counterparts."
In general, minorities -- especially blacks -- have higher rates of illness and death, and less access to the type of care that could help them.
"There's evidence that African-Americans tend to receive less care for chronic conditions, in spite of the fact that African-Americans and other minorities have a higher incidence of a wider variety of illnesses and shorter life spans," says Dr. Eric Krakauer, lead author of the paper.
Minorities, for instance, are more than twice as likely to go without health insurance, says Krakauer, associate director of palliative care service at Massachusetts General Hospital.
If and when they get the care they need, it's often substandard. One of the most famous studies in this area, published in 1999 in the New England Journal of Medicine, had 720 physicians look at videotapes of actors playing patients experiencing chest pain. Although all the actors showed the same symptoms, the researchers found that blacks were less likely to be referred for catheterization than whites, while black women were even less likely to be referred than black men.
When it comes to end-of-life care, certain issues become particularly relevant. One is pain relief. Here again, research has unearthed startling disparities in access to pain relievers. Studies done by physician Todd Knox in Los Angeles and Atlanta found that both Hispanics and blacks who went to emergency rooms with long-bone fractures were less likely to receive analgesics than similarly injured white patients.
A study published in the New England Journal of Medicine in 2000 found that 51 percent of pharmacies in nonwhite sections of New York City did not carry commonly prescribed opioids to treat patients with severe pain. Only 25 percent of these inner-city pharmacies had sufficient supplies of these drugs, compared with 72 percent in predominantly white neighborhoods.
"It's absolutely intolerable that there might be a cultural group that doesn't have equal or fair access to pain relief," says Krakauer. "It's just absolutely unacceptable."
Cultural differences also tend to become pronounced when a person is dying.
"The particularly acute and intense stress of dying can accentuate cultural differences because people tend to fall back on cultural and religious practices, beliefs, and values in most stressful situations," says Krakauer. "Health-care providers also rely on their own cultural values and beliefs, including the culture of medicine, and therefore that particular stress in the time of dying can accentuate cultural differences between physicians and patients and their families."
Studies also show that minorities also tend to distrust the health-care system, an attitude Krakauer attributes to a long history of medical racism in this country. A good example is the Tuskegee Syphilis Study, conducted from 1932 to 1972, which tracked the progression of untreated syphilis in 399 African American sharecroppers who had been tricked by the U.S. government into participating in the study.
Krakauer calls for more action and more research to correct these inequities.
"It's not hard to really make a big difference, and help turn a death which is a tragedy into a celebration of someone's life and a time when families can come together and support each other," says Krakauer.
What To Do
An Institute of Medicine study due out later this month documents more than 600 studies showing bias and discrimination by race in health care. To get information on the report when it's released, visit the the IOM.
For more information on Krakauer's work on end-of-life issues, visit Massachusetts General Hospital's Palliative Care Service.
For more information on health issues affecting minority groups, visit the U.S. Department of Health and Human Services or the National Institutes of Health Office of Research on Minority Health.