Affirmative Action in US Medicine

From Sally Satel, P.C. M.D. : How Political Correctness is Corrupting Medicine (New York, Basic Books, 2000). Previous extracts posted here. Reference is made in these excerpts to ‘Tuskegee’ - commonly the ‘Tuskegee experiment’ - for a more balanced view than the common one see ‘Tuskegee Re-examined’ by Richard A Shweder.

Rationale for Affirmative Action in Medical School

Whether the quality of health care for minority patients truly depends on producing greater numbers of minority physicians is an unresolved empirical question. If anything, the evidence we have thus far suggests that the answer is no. Nonetheless, proponents of racial preferences in medical school admissions contend that white physicians treat white patients better than minority patients, with whom, it is said, they have difficulty developing a rapport. “This is not a quota born out of a sense of equity or distribution of justice, but a principle that the best health care may need to be delivered by those that fully understand a cultural tradition,” says George Mitchell, the former Senate majority leader and the chairman of the Pew Health Professions Commission.

To be sure, understanding a patient’s cultural tradition is important, but need one be a product of that tradition to have sufficient sensitivity to the patient? Virtually all of the major medical organizations, including the AMA and the federal Council on Graduate Medical Education, say yes. Foremost among them is the Association of American Medical Colleges. When California and Texas were planning to dismantle racial preferences in 1990, the AAMC formed Health Professionals for Diversity, a coalition of major medical, health and educational associations, to lobby for the preservation of preferences. By the time Initiative 200, the Washington State referendum to prohibit preferences by race, ethnicity or sex in public institutions, was on the ballot in 1998, the coalition included fifty-one associations among its membership. According to an association

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vice president, the true message of race-neutral policy to minority students is: “We don’t want you.”

Given the relatively small numbers of black, Hispanic and Native American physicians (3 percent, 5 percent and less than 1 percent of the nation’s medical workforce, respectively), compounded by the declining number of minority applicants in the late 1990s, medical schools know they need to rely on racial preferences if they are to boost these numbers in the next few years. Thus, a few weeks before Washington State voters were to cast ballots on initiative 200, the AAMC made a highly visible appeal in newspapers. It ran a full-page ad in which eight doctors appear under a huge banner headline: “The Toxic Side-Effects of initiative 200.”

The AAMC’s ad warned readers that without racial preferences in Medical school admissions, minority Americans will not get the health care they need. After all, the association argued, minority physicians tend to serve black, Hispanic and poor patients more often than white physicians do and are more likely to practice in poor neighborhoods. In addition, the association pointed out, minority medical students often state that they want to practice in medically underserved areas. The ad was also quite specific in predicting that, with fewer minority researchers, less progress will be made in dealing with sickle-cell anemia, prostate cancer and infant mortality - all conditions that disproportionately affect African Americans.

The Current Status of Minorities in Medical Schools

Blacks, Hispanics and Native Americans together represent more than one-fifth of the nation’s population but less than one-tenth of the physician workforce. As such, they are underrepresented minorities, or “URMs,” as the Association of American Medical Colleges refers to them. Asian Americans are not considered a minority because they are well represented among practicing physicians -10 percent versus 4 percent of the general population - and they represent 18 percent of medical school graduates.

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Racial preferences have played a role in raising first-year enrolment to the point where, by 1999, it reached 8 percent black and about 7 percent Hispanic, though it remains 1 percent Native American. But recruitment has been difficult. In 1995, when racial preferences in medical schools were nearly universal, only about 12 percent of first-year students were black, Hispanic or Native American. Robert G. Petersdorf, former president of the AAMC, describes the recruitment challenge: “We cannot produce underrepresented minority medical students if there is an insufficient number who are applying to our schools, graduating from college, or even finishing high school with sufficient skill to enable them to survive a premedical course of study.”

Nonetheless, by 2010 the AAMC hopes to attain racial and ethnic representation among physicians that is in proportion to the general population. That goal will be unreachable if current trends continue, according to Donald L. Libby of the Wisconsin Network for Health Policy Research and his colleagues. Based on a minimum requirement of 218 physicians per 100,000 population, Libby calculates that, starting in 1998, the annual number of first-year residents must roughly double for Hispanic and black physicians and triple for Native American physicians if parity is to be attained by 2010. Simultaneously the number of white first-year residents will have to be reduced by about two-fifths and the number of Asian first-year residents by two-thirds.

The impact of race-neutral policies in some states will make the 2010 parity goal even more elusive. Within two years after Proposition 209 passed in 1996, there was a 29 percent drop in applications by minorities to six public medical schools in California. This set alarm bells ringing throughout the medical establishment. “There is a national health need for physicians who, after the Tuskegee Syphilis Study, for example, are trusted by large segments of our population.” wrote Michael J. Scotti Jr. of the American Medical Association. “It would be deplorable,” he continued, “if medical schools were not permitted to consider the needs of patients when determining their criteria for selecting the best qualified applicants.”

David M, Carlisle and his colleagues at the UCLA School of Medicine proclaimed it a “tragedy that medical students may think they are not wel-

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come . . . within the medical profession.” Randall Morgan, an orthopaedic surgeon and former president of the National Medical Association (NMA), which represents more than twenty thousand of the nation’s African American physicians, said: “War must be declared on any and all attempts to limit access to medical education for students who comprise the under-represented minorities.” In protest of the passage of Initiative 200 in Washington, the NMA pulled its 2001 annual meeting from Seattle.

Perhaps the most overwrought statement came from H. Jack Geiger, a professor of public health at the City University of New York. His essay in the American Journal of Public Health, “Ethnic Cleansing in the Groves of Academe,” foresees these “reversals in minority admissions [as] merely the leading edge of a potential public health disaster.” A public health disaster? Only if there is nothing more important to Americans about their doctors than race.

Academic Performance and Racial Preferences

In 1976 Bernard D. Davis, a Harvard microbiologist, found himself at the epicenter of the debate about racial preferences, That year he published an essay in the New England Journal of Medicine questioning whether “we have been properly balancing our obligation to promote social justice with our primary obligation to protect the public interest.” In his book Storm Over Biology, he elaborated on Harvard Medical School’s Affirmative action strategy. The Medical school dean, Davis said, purposely deprived the medical school faculty of objective feedback on student performance on part of the National Board exam, a test given halfway through medical school: “In the past, the ranking of our students in the National Board Examinations, in each subject, was presented each year at a faculty meeting, and any department that fell below third place in the country virtually apologized. Shortly after the new [minority admissions] program started, the dean’s office quietly dropped this annual report.”

Eventually, Davis reported, even the National Boards (since replaced by an exam called the United States Medical Licensing Examination) became optional in some cases. He cited the specific example of a minority student who failed the boards five times but whom the dean still decided to graduate.

After the publication of his essay Davis was attacked by the Harvard Crimson, picketed by students, roundly criticized by the dean of the medical school and verbally assailed by some of his colleagues. Ultimately, some other colleagues rallied around Davis, pointing out that lowering standards would unfairly put into doubt the qualifications of black and other minorities who would he admitted in the future.

Davis wrote his essay in 1976, but almost twenty-five years later the admissions practices he brought to light still go on in medical schools

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around the country. Acceptance rates for minority students have long been higher than for white applicants with similar qualifications, according to the Association of American Medical Colleges. In 1979, for example, a minority student with high grades and board scores had a 90 percent chance of being admitted to medical school, while a white applicant with comparable qualifications had a 62 percent chance. By 1991, the last year for which AAMC has published data, the figures were 90 percent versus 75 percent, Conversely, a low-scoring minority applicant had a 30 percent chance of admission while a similarly low-scoring white applicant had a 10 percent chance.

At the University of South Florida College of Medicine, for example, black applicants with a B-plus grade point average (GPA) had a roughly 13 percent chance of admission between 1995 and 1997, but white and Hispanic applicants with the same GPA had only a 4 to 5 percent chance. Despite the passage of Proposition 209 in 1996 in California, minority applicants to some of California’s public medical schools were two to almost three times as likely to be admitted as whites and Asians with considerably higher grades.

During the years 1987 through 1993, the medical school of the University of California at San Diego was applying racial preferences. Students accepted through affirmative action had far lower premed course grades and MCAT (Medical College Admissions Test) scores than their fellow white and Asian students. More precisely, the average student accepted through affirmative action had scores comparable to to the lowest 1 percent of his white and Asian counterparts. Not among those white students in 1992 was a brilliant computer science major named James Cook. Even though he had graduated Phi Beta Kappa from UC San Diego, he was rejected by its medical school, and all the other public California medical schools to which he applied.

Cook’s parents were dumbfounded by their son’s across-the-board rejection in his home state - especially since he was accepted by the Harvard Medical School. Moved to action, his father obtained copies of the academic records of the students who were admitted to San Diego’s medical school over a period of several years. (The race but not the names of the students were made available to Mr. Cook.) With the scatterplots of

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student scores spread out before him, Cook saw that minority students with lower grades were distinctly favored over white and Asian students with higher grades. In 1994, when he presented the data to a regent of the University of California named Ward Connerly, he touched off the anti-affirmative action campaign that ultimately rocked the state.

Not only are black and Hispanic applicants favored in medical school admissions, but they are over-represented among students who encounter trouble in medical school. According to the AAMC, they are more likely to repeat their first year or drop out. For the medical school class admitted in 1984, over 20 percent of minority students did not graduate four years later, as is typical. Among white and Asian students, 8 percent did not graduate that year. In 1996 the picture worsened across the board: 39 percent of minority students were unable to keep pace, compared with 15 percent of non-minority students. A 1994 study published in the Journal of the American Medical Association found that, in 1988, 51 percent of black medical students had failed part 1 of the National Medical Boards (taken after the second year of medical school), over four times the rate of white students, which was 12 percent. (Failure rates for Hispanic students were 34 percent, and for Asians 16 percent.)

The typical path for students after graduating from medical school is application to a residency program in their chosen specialty. At this level there have also been different outcomes. “It has been documented consistently over the past decade that a higher proportion of underrepresented minority students failed to obtain first year residency positions through [the standard process],” writes Gang Xu of Jefferson Medical College in Philadelphia and colleagues. Also, the yearly dismissal rate for black residents (14.4 percent) was almost double that for other groups (7.7 percent) from 1996 to 1999. Reasons for dismissal from a residency program can include persistently unprofessional behavior, chronic absenteeism and lack of aptitude or interest.

The problems encountered by black and Hispanic students result from having been under-qualified when admitted to medical school. When black students were compared with whites who had similar academic credentials, the failure rates were similar. A 1987 Rand study found that only about one-half of black physicians obtained board certification com-

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pared with 80 percent of white physicians. Yet African Americans were more likely than white physicians to obtain board certification in a recognized medical specialty if their grades in college and on the Medical College Admissions Test were strong enough to get them admitted on a competitive basis in the first place.

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An Honest Debate

Instituting racial preferences to achieve the goal of diversity for its own sake or in the spirit of compensation for historical mistreatment are

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philosophical abstractions for debate in courtrooms, classrooms and legislatures. Instituting preferences in order to enhance minority health, however, is a practical proposition that can be tested using real-world data. Thus far, the case has yet to be made that improving minority health depends on having more minority doctors.

It appears that racial preferences represent an inefficient way to increase the number of minority doctors - and thus minority health - for a number of reasons. First, minority representation in medical schools remains well below their representation in the general population, despite aggressive admissions policies. Second, minority recruitment has resulted in a two-tiered system of academic standards for admission. This has created attendant problems: some potential non-minority medical students have not been treated fairly, while some minority students have embarked upon a career for which they are ill prepared. Third, we lack compelling evidence that same-race (minority) doctor-patient relationships result in better patient outcomes.

No matter who treats our nation’s poor and minority patients, the fact is that they tend to have multiple , chronic medical conditions and are often clinically complicated. They need the best doctors they can get, regardless of race. Fortunately, inner-city poor and minority patients are most likely to get their care in high-volume municipal hospitals that are associated with academic medical centers and thus have better access to resources and technical support. They employ experienced physicians who perform hundreds of the same operations each year. Over half of all patients hospitalized in major teaching hospitals in 1995 were uninsured, poor or minority, a Rand evaluation found. Black and poor patients received better care in urban teaching hospitals than white and more affluent patients received in rural or nonteaching hospitals.

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The racial disparities in health are real, but data do not paint convincingly to systematic racial bias as a determinant, Nor does the evidence suggest that racial preferences in medical school admissions are the remedy for health disparities.

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How Political Correctness is Corrupting Medicine

Brit nationalist blogger John of Gwent has written about the situation in Britain of ethnic minorities needing more organs for transplant than they provide to the organ bank, yet another subsidy we provide for the parasite groups. Unsurprisingly, the situation in America is the same, and yet still there is the complaint that Blacks suffer discrimination in the organ donor process, an issue reported on in Sally Satel, P.C. M.D. : How Political Correctness is Corrupting Medicine (New York, Basic Books, 2000), chapter 6, ‘Race and Medicine’:

According to new conventional wisdom … [a] mismatch in race between doctor and patient - especially when the doctor is white and the patient is not - may be enough to trigger subtle, or not so subtle, biases that result in second-rate medical treatment and poorer health. “It is increasingly evident that African-Americans and other minority patients have strong grounds for doubting both the goodwill and the color-blindness of White medical practitioners,”

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writes Kenneth DeVille of the Department of Medical Humanities at the East Carolina University School of Medicine. No less authoritative a voice than the American Medical Association’s official newspaper has claimed that “growing body of research reports that racial disparities in health status can be explained, at least in part, by racism and discrimination within the health care system itself.” This is why, according to the Reverend Al Sharpton, health will be the “new civil rights battlefront,” a prediction echoed by other black leaders, including the Reverend Jesse Jackson, NAACP chairman Julian Bond and the Congressional Black Caucus.

In a 1998 radio address delivered during Black History Month, President Clinton spoke of race and health, “Nowhere are the divisions of race and ethnicity more sharply drawn than in the health of our people.” It is indeed true that black Americans are less healthy than whites and Asians on a number of measures, such as life expectancy, infant mortality and death from cancer. This often remains true even when insurance coverage is taken into account. Beyond these facts, the president could only speculate when he said that perhaps one of the reasons for racial disparities is “discrimination in the delivery of health services.”

Given the history of systematic racial discrimination and segregation in the health care system, lingering bias seems, at first, plausible. Black patients were treated in separate and inferior hospital wards - a policy that persisted at many hospitals in the Deep South until the late 1960s. Once routinely barred from joining hospital staffs and medical societies, black physicians started their own institutions to treat other blacks who were denied adequate care by the white-controlled medical facilities. As late as the mid-1960s several medical schools had restrictions against admitting black students.

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[…] Decades later however, accusations of medical bias still linger… In the fall of 1999 the US. Commission on Civil Rights informed Congress and the White House that “racism continues to infect the health care system.” Earlier that year an official of the Association of American Medical Colleges commented on physicians’ unwitting biases. “Most doctors think they are fair,” he told the Boston Globe. “That they carry bias is very hard for them to think about.”

For her part, Leslie Pickering Francis, a medical ethicist at the University of Utah, prefers to believe that “racism [is] the presumptive cause of health care problems minorities face” until there is evidence to the contrary. This view is increasingly common - not too surprising considering the habit nowadays of presuming that discrimination inevitably lies beneath the surface of any race-related difference in social outcome. But evidence suggests that many race-related differences in health are not what they seem to observers like Professor Francis, Reverend Sharpton and the Commission on Civil Rights.

The charge of physician bias against minority patients is often made reflexively, overlooking the myriad complicated reasons for differences in care. In this chapter I present evidence that supports other interpretations of “health disparities” as they are often called. As we will see, the race-related differences that do exist in both access to health care and in health status are better understood - and remedied - from the vantage points of clinical need and health care financing - not race politics.

Do Physicians Treat Minority Patients Differently?

A study in the New England Journal of Medicine in 1999 described differences in the treatment of lung cancer between black and white patients who were beneficiaries of Medicare insurance. In a careful analysis, Peter B. Bach and his colleagues cat Memorial Sloan-Kettering Cancer Center in New York City looked at the records of more than ten thousand patients who received diagnoses of operable lung cancer. Seventy-seven percent of the white patients underwent surgery compared with 64 percent of the black patients. Five years after diagnosis, only one-quarter of black patients were still alive compared to one-third of whites.

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What accounts for the different rates of surgery? Did doctors not suggest the treatment as often to their black patients, or did these patients more often refuse the recommendation for surgery? Were the black patients more likely to have poor lung function, such as more carbon dioxide build-up, or other problems that would have prohibited surgery or contributed to earlier demise? Details like these are crucial in explaining why surgery was used less for black patients and why death rates differed, but those were not the questions that Bach and his colleagues set out to answer. Indeed, the authors themselves said they could not offer an explanation for different rates of surgery based on the kinds of data they collected.

Other physicians, however, were ready with hypotheses. “Possibly, physicians are treating cancer patients not just based upon their illness and recommended treatment, but on the basis of their race,” suggested Dr. Hugh Stallworth of the American Cancer Society. A more emphatic reaction greeted a report in the Annals of Emergency Medicine that 74 percent of white patients with fractures of the extremities received pain medication in the emergency room compared with 57 percent of black patients. “I think it’s racism, flat out,” said Dr, Lewis Goldfrank, director of emergency services at Bellevue Hospital in New York City.

Responses like these would probably not surprise John Landsverk of Children’s Hospital in San Diego. As he observes: “The usual implication of such disparities (in treatment rates) is that the health care system is biased against persons of the ethnic minority group and that the bias is likely to be found even in professional clinicians’ perceptions of clinical problems and (referrals for) clinical procedures.”

In light of this, Landsverk is especially enthusiastic about one study led by a group of doctors from the University of Pittsburgh that found no race-related differences in the treatment of children with behavioral problems. Their report appeared in the journal Medical Care one month after

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Bach’s study that attracted little public attention. It should have: it was “an important nonfinding,” as Landsverk notes in an accompanying editorial in the same journal. Not only did the Pittsburgh study include a very large sample - almost fifteen thousand children treated in clinics across the country and Canada - but most important, the researchers interviewed the parent and doctor of every patient. The results: the race and ethnicity of the child had no relationship to clinician patterns of drug prescribing, referral or diagnosis of behavioral problems. The clinicians also reported spending slightly more time with minority children than with their white counterparts.

The handful of studies just discussed gives a taste of the challenges inherent in interpreting health disparities data. First, the vast majority of treatment disparity studies are what scientists call “retrospective.” That is, the raw data already exist in hospital records, and researchers use them (in retrospect) to explore a specific question. (For example, are there more visits to emergency rooms on nights with a full moon?) The disadvantage of this approach is that key questions cannot be asked directly of the very people being studied: for example, in the case of the lung cancer study, did subjects want or refuse a specific treatment? Did their physicians offer it, and if not, why? Second, as Landsverk’s reaction to the University of Pittsburgh study suggests, the absence of alleged racial bias does not make news. Consider the following example of a study that made a media splash the first time around.

A Misdiagnosed Case of Physician Bias

Cardiac catheterization is a procedure used to discern whether there is blockage in the coronary arteries - the vessels that feed blood to the heart itself - and thus whether the patient is at risk for a heart attack. The delicate process involves introducing a catheter into an artery in the leg and threading it upward toward the heart. When it reaches the point near the apex of the heart where the coronary arteries branch off, dye is squirted in, and the arterial patterns show up on a real-time X-ray. This is generally the first step in determining whether the vessels can be opened wider

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using a tiny balloon (balloon angioplasty) or whether some or all of the vessels must be replaced in a bypass operation.

Struck by the observation that black patients undergo catheterization less often than whites, Dr, Kevin A. Schulman and others at Georgetown University Medical Center wanted to examine how doctors make their decisions to refer patients for the procedure. The researchers recruited 720 general internists at medical conventions and asked them to participate in a study of clinical decision-making. The internists were not told that a primary purpose of the study was to explore how the race and sex of the patient might affect those decision, or that the researchers expected to find that African Americans (and women) would be referred for cardiac catheterization less frequently than white men.

The doctors watched a video of actors wearing hospital gowns and answering questions posed to them by an interviewer who elicited their complaints about chest pain and other relevant medical and personal history. The viewing doctors were informed of the actor-patients’ insurance types and their occupations. All the questions asked of the actors and their responses, down to the gestures they used in describing their symptoms, were scripted to minimize inconsistencies. As a group, the doctors, most of whom were white, viewed 144 different videotapes, one for every possible combination of race (black or white), sex (male or female), and age (fifty-five and seventy years old), and including different clinical variables, like the nature of the chest pain and EKG and stress test results. Individual doctors were shown one randomly selected video.

Next, the physicians were asked whether the patients’ complaints appeared to reflect heart disease or another kind of distress, such as indigestion, and to rate the likelihood that the pain was indeed heart-related. As it turned out, all eight actor-patients received similar ratings from the doctors, leading the authors to assume the doctors would refer the catheterization at similar rates as well. Yet this did not happen; according to Schulman, “women and blacks [in the study] were less likely to be referred for cardiac catheterization than men and whites.” Doctors did not refer white men about 9 percent of the time, while the black actor-patients

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and women of both races did not get referred 15 percent of the time. If representative of actual clinical outcomes, Schulman told the media, this would mean that blacks are “40 percent less likely to be referred for cardiac catheterization compared to whites.” He misspoke, however; what it really would mean is that white patients have a forty percent lower chance of not being referred. Quite a difference, as we will see.

These findings were presented in an article titled “The Effect of Race and Sex on Physicians’ Recommendations for Cardiac Catheterization,” published in the New England Journal of Medicine in February 1999. Schulman and his associates speculate:

Our findings that the race and sex of the patient influence the recommendations of physicians independently of other factors may suggest bias on the part of the physicians. However, our study could not assess the form of bias. Bias may represent overt prejudice on the part of the physicians, or, more likely, could be the result of subconscious perceptions rather than deliberate actions or thoughts. Subconscious bias occurs when a patient’s membership in a target group automatically activates a cultural stereotype in the physician’s memory regardless of the level of prejudice the physician has.

The study was a media sensation. On ABC’s World News This Morning, Juju Chang told viewers, “How your doctor treats your heart may depend on the color of your skin … The bias shows up in the diagnosis and the doctors don’t even realize it.” Peter Jennings predicted that the study would make “political waves” because it showed that “prejudice among doctors causes a gap in the quality of health care between blacks and whites.”

On Nightline, Ted Koppel set up the story like this: “Last night we told you how the town of Jasper, Texas, is coming to terms with being the place where a black man was dragged to his death behind a truck by an avowed racist. Tonight we’re going to focus on [doctors] … who would be shocked to learn that what they do routinely fits quite easily into the category of racist behavior.” Newspaper headlines echoed the theme:

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“Cardiac Testing: Study Finds Women, Blacks are Being Shortchanged,” the Chicago Tribune said. “Health Care: It’s Better if You’re White,” announced The Economist. And all the articles repreated Schulman’s claim that blacks were forty percent less likely to be referred.

Some of the most intense - indeed, self-flagellating - reactions came from the medical profession itself. An editorial in the Lancet, Britain’s foremost medical journal saw the findings as being “as close to a definition of institutional racism as doctors and health-care providers may dare to get.” Aubrey Lewis, a Long Island cardiologist warned on Nightline that “if this [physician bias] continues on, you’re looking at literally a decimation of the African American population.”

No-one seemed to notice another article, published earlier that same February, in the Annals of Internal Medicine by the Harvard researcher Lucian L. Leape and his colleagues. In their evaluation of thirteen New York city hospitals. Leape’s group found that African American patients are as likely to undergo cardiac bypass or balloon angioplasty as whites and Hispanics, and in some hospitals more likely to receive a recommendation for these procedures.

A Second, Sober Look at Schulman’s Study

A careful look at the work of Schulman and his colleagues reveals a number of intriguing things. One is the doctors’ impressions of the subjects: one might be surprised to find that they found the white actor-patients to be the least agreeable. When asked, for example, to rate their impressions of the subjects’ personal characteristics, the doctors rated the white men as more “hostile” and gave them the lowest ratings on scales that ranged from “ignorant” (lowest score) to “knowledgeable” highest score” and from “poor communicator” to “good communicator.” Similarly, doctors judged white men to be more “dependent” than their black counterparts, more “sad,” more “negative” in disposition, more “worried” and more “likely to over-report symptoms.”

Finally, the white males were judged “most likely to sue.” With such a litigious profile, one might have expected white men to be over-referred by physicians in order to avoid malpractice lawsuits.

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The second revelation came six months after the Schulman study appeared, when the New England Journal of Medicine itself published a powerful rebuttal. Lisa M. Schwartz, Steven Woloshin and H. Gilbert Welch, all physicians at the White River Junction Veterans Administration Hospital in Vermont, reanalyzed Schulman’s data and showed that the actual referral rates for three of the four groups were in fact the same. White men, white women and black men were all referred by nine in ten doctors. Only black women, for reasons that remain unclear, had a lower referral rate: about eight in ten. Put another way, the black women were eighty-eight percent as likely as white women and men of both races to be referred for catheterization in the actor-patient study.

The doctors from White River Junction also expressed dismay at what might be called the statistical sleight-of-hand that Schulman and his colleagues used to support their hypothesis of physician referral bias in favour of white men. It was only because Schulman and colleagues combined the referral rates for black men (91 percent) and black women (79 percent) to yield an 85 percent black referral rate that they could conclude that the racial differences were so marked. This maneuver led to the “mistaken impression that blacks had a forty percent lower probability of referral than whites, whereas, in fact, the probability of referral for blacks was 7 percent lower,” wrote the White River Junction doctors. “These exaggerations serve only to fuel anger and undermine the trust between physicians and their patients.” Schwartz and her colleagues were not alone in expressing concern; the NEJM editors published a note in the same issue regretting that they had not required the authors to use more straightforward statistical measures. “We take responsibility for the media’s overinterpretation of [this] article … The evidence of racism and sexism in [the Schulman] study was overstated,” the editors wrote.

Nevertheless, even after seeing how his findings had been interpreted by the press and used to goad racial resentments, Schulman wouldn’t budge. “Our study … will encourage the medical profession to seek ways to eliminate unconscious bias that may influence physicians’ clinical decision,” he maintained. Schulman also met with the Congressional Black Caucus at its invitation and briefed the members on bias in the health care

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system. Also sticking with Schulman’s interpretation was Paul Douglass, a cardiologist at Morehouse school of medicine. “You can argue with statistics all day,” he told USA Today. “We have to face the reality of our situation: there is a gender and racial bias.” Compared with the tidal wave of coverage triggered by the Schulman study, the article by Schwartz and her colleagues generated a mere trickle of media interest, as noted by the columnist John Leo and the media magazine Brill’s Content.

Alternative Explanations for Differences in Treatment

Less eye-catching than accusations of bias are the everyday aspects of clinical care that account for many of the recorded disparities. For example, one reason procedure rates differ is that medical problems do not necessarily occur with the same frequency across races. [..] Consider these facts: uterine fibroid tumors, and thus hysterectomies, are more common in black women than in whites, while osteoporosis-related fractures, and thus hip-replacement are rarer. Limb amputation is more common among black patients, typically because thicker atherosclerosis of the blood vessels in the leg makes it harder to perform limb-saving surgery.

African Americans suffer stroke at many times the rate of whites yet undergo a procedure to unclog arteries in the neck (endarterectomy) only one-fourth as often. Racism? Unlikely. Some studies have documented a greater aversion to surgery and other invasive procedures among African American patients, but the more substantial reason, in the case of endarterectomy, is clinical. It turns out that whites tend to have their obstructions in the large, superficial carotid arteries of the neck region, which are readily accessible to surgery. Blacks, by comparison, tend to have their blockages in the branches of the carotids. These smaller vessels run deeper and further up into the head where the surgeon cannot reach them.

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Thus, even without financial obstacles, an African American patient at high risk for stroke is far less likely than a white counterpart to undergo endarterectomy. Yet indoctrinologists like David R. Williams, a sociologist at the University of Michigan’s Institute for Social Research, are quick to turn this disparity into evidence of bias. After all, they argue, if money is not an issue, then the difference in treatment must represent bias on the part of the doctors. American Medical News, the newspaper of the American Medical Association, gives voice to this view: “National studies, such as the one that examined care at Dept. of Veterans Affairs medical facilities - where all of the patients have comparable insurance coverage - suggest ‘racial disparities in the quality of medical care do not merely reflect the behavior of a few bad apples,’ Dr. Williams said. ‘The evidence is too overwhelming and the pattern is too pervasive.’ ”

Williams seems not to consider a different interpretation: the patients’ clinical needs rather than the doctors’ personal biases are dictating the care. Think about it. If not for concern about the patient (many of whom are treated in private hospitals and have medical insurance), why wouldn’t physicians perform a reimbursable procedure?

Another consideration in performing procedures is the clinical condition of the patient. Does he have other medical problems that alter the risk-to-benefit ratio of a procedure and make the outcome less favorable? The treatment of heart disease, for example, often needs to be modified in the presence of uncontrolled high blood pressure and diabetes - conditions more typical of black patients with heart disease than of their white counterparts.

Then there is the site of care itself. Some hospitals simply do not offer certain cardiac procedures, such as bypass grafts or balloon angioplasty. Examining a sample taken from New York City hospitals, Dr. Lucian L. Leape of the Harvard School of Public Health and his colleagues found that about one-fifth of all patients needing these procedures do not get them, largely because those hospitals do not offer them. Leape found that failure to recommend these procedures - and hence to transfer a patient to a hospital where it could be performed - is equal across all groups of black, white and Hispanic patients. Conversely, when medical care is readily available for special patient populations (for example the veterans’

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affairs medical centers or the military service), racial differences in treatment and outcome can melt away. For example, veterans with colorectal and prostate cancer show no race-related differences in treatment availability, treatment methods or survival rates.

Fairness and Kidney Transplantation

Patients’ attititudes toward illness and care also play a role in determining the treatment they receive. The nature of their belief in their personal susceptibility to disease, the seriousness with which they perceive disease, their confidence that the treatment will work - and even that the medical system is benign - are all relevant. Differences in health benefits account for some of the reluctance in the African American community to donate (and sometimes receive) kidneys, according to Dr. Clive O. Callender, head of transplant surgery at Howard University Medical Center in Washington, DC.

Callender tells me that, compared to whites, African American patients are less trustful that they will be well cared for, whether as a living relative undergoing surgery to donate a kidney or as a patient undergoing transplant surgery to receive one. Some fear that signing a donor card will lead to premature declaration of death. Others express concern that a deceased donor will either be disfigured or unable to get into heaven without all his body parts. A potential recipient ay also object on religious grounds to having the tissue of a dead person in his body. Moreover, blacks are not as likely as whites to believe that people who get transplants gain additional healthy years of life.

To enhance recruitment of African American donors and dispel the myths surrounding donation, Clive Callender directs the national Minority Organ Tissue Transplantation and Education Program (MOTTEP), which operates in over a dozen cities. Understanding patients’ objections to donation and demystifying the process is critical because severe (or “end-stage”) renal disease is about four times as common in blacks than in whites and , as we will see, there are considerable benefits to receiving a kidney from a living donor of the same race.

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To create incentives for organ donation and expand the black organ donor pool, Wayne B. Arnason, a minister writing in the Hastings Center Report, has proposed an experimental protocol that would try to pair a black donor kidney with a black recipient, some African Americans have expressed a desire that their organs be earmarked for black recipients. Arnason’s proposal addresses the fears of some black patients that they are being discriminated against in the kidney transplantation process, fears stoked by observers like David Barton Smith, a sociologist at the University of Michigan, who asserts in his 1999 book Health Care Divided: Race and Healing a Nation: “The assumptions that served as justification for the Tuskegee Study remain in evidence among those providing health services to [the black] population . . . Blacks have lower rates of kidney transplants . . . even where no differences in insurance or ability to pay exist.”

This matter has attracted the attention of a wide spectrum of advocates, from the Reverend Louis Farrakhan (who has said that whites condone black-on-black killing as a source of transplantable organs) to law professors who propose suing the federal government for violating civil rights laws in the allocation of organs. The US Commission on Civil Rights has also weighed in: “Black patients remain less likely than other minorities and whites to receive a kidney transplant,” it reported in 1999, calling this “an aspect of health care inequality that thus far seems to have eluded the [HHS’s] Office of Civil Rights.”

To assess the fairness of the charges levied by the Commission on Civil Rights and others we must first walk through the steps involved in donating and receiving a kidney. The road starts at renal dialysis. Every two or three days patients with end-stage kidney disease undergo a process called renal dialysis while they wait far a kidney to become available. During the three-to-four-hour dialysis process, patients are hooked up to a machine that acts as an external kidney, removing the fluid and metabolic by-products that are normally cleared by the kidney and excreted as urine. For unclear reasons, black patients, on average, tolerate dialysis better than white patients - who are more likely than black patients to die while on the waiting list - and blacks can be

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maintained longer in a healthy state before transplantation. Just the opposite is true, however, once the operation has taken place: black patients, on average, do not tolerate the transplant organ as well as whites, and they must return to dialysis support sooner and more frequently.

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[…] Another key aspect of the transplantation process is the patient’s interest in receiving a kidney. United Network for Organ Sharing (UNOS) data suggest that African American patients decline the procedure more often than do whites. Reports have documented that black transplant candidates were more often undecided, more apt to decline the transplant operation at the last minute, more often unavailable owing to illness and more likely to be unlocatable when a kidney became available.

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[…] [T]he remedy for recruiting more organ donors is better education of both medical personnel and the public.

[…] Combining these principles - with better education for the public through a program like Clive Callender’s MOTTEP seems most promising. Simply getting more people to have a family discussion about donation is important because families are more likely to agree to the donation process if they know the deceased had previously expressed a desire to give his organs. The MOTTEP program also involves explaining the biology of matching and the nature of the surgical procedure, and working with churches to dispel religion-based myths. Callender’s results are encouraging: by the late 1990s 45 percent of kidneys transplanted at Howard University (a predominantly African American institution) were from black donors; a decade earlier the figure had been under 20 percent.

Fairness Continued

Now let us turn to the clinical aspects of transplantation. A crucial dimension is tissue compatibility. Without a good “match” the donor kidney will provoke the recipient’s immune system to attack or “reject” it. The better the match on biological variables, the better the outcome, Accord-

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-ing to a report issued by the UNOS Histocompatibility Committee, black patients in need of a transplant wait longer owing to factors such as blood type, sensitization and some antigens. Similarly, Rand researchers found that “once a patient is on the waiting list, biological factors may predominate” in explaining his lower chances of receiving a kidney.

A technique called antigen matching is used to test for different combinations of six major antigens, or proteins, found on the surface of tissues. A perfect six-out-of-six match is the ideal condition for compatibility between donor and recipient. A complete match is far less common in African American transplant candidates than in whites because they have more possible antigen combinations than whites do, and some of those antigens are very rare in the general population. Scientists are still debating the precise physiology of organ rejection, and particularly the extent to which the organ is jeopardized by less-than-perfect antigen matching. What they do know is that black transplant recipients are more likely to reject their new kidneys. Possible reasons include poor control of hypertension or a more vigorous immune response. Even well-matched transplants can be lost to rejection, suggesting that the standard antigen-matching system may be too simplistic.

[…] To circumvent some of the biological constraints, physicians encourage donation of a kidney from a living relative so that the chance of a match will be enhanced. Living donation is also promoted even if the donor is not related and not of the same race because there is so much

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added benefit from getting a fresh kidney - one that goes straight from the operating room of a healthy donor to the operating room of the recipient without spending too much time on ice. In fact, along with tissue compatibility and the clinical condition of the recipient, the amount of time spent in “cold storage” is one of the most important factors in the successful functioning of a transplanted organ.

Getting a live kidney has little to do with the medical establishment and a great deal to do with the health and attitude of one’s family and others of one’s own race. Unfortunately, the black donation rate from living individuals is very low relative to need. In 1998, for example, 438 living kidneys were donated by African Americans, but 14,923 African Americans needed a kidney (a ratio of 3 donated per 100 needed), while 2,559 whites gave live kidneys and 20,616 were in need (a ratio of 12 per 100). In addition to personal reluctance and wariness of the system, the low rate of black live donations relative to need is due in part to the fact that so many potential donors are not eligible to give a kidney because they suffer from hypertension or diabetes, conditions that diminish the health of their kidneys. UNOS data show that in 1998 almost one-third of all transplant candidates received a living kidney: 73 percent of those kidneys were given by white individuals to their relatives or friends, and 13 percent by African Americans to theirs.

Most patients on dialysis, especially black individuals, receive an organ from a deceased donor; a so-called cadaveric donor. Once on the waiting list, how do black patients fare in the allocation of kidneys from cadavers? In 1998 African Americans represented 36 percent of the waiting list for kidneys; as a group, they donated 11 percent of all cadaveric kidneys (proportionate to their representation in the general population) and received 27 percent of all donated kidneys.

Thus, more than half of all cadaver kidneys received by black transplant recipients came from donors of other races (predominantly white). As Maritza Rozon-Solomon and Dr. Lewis Burrows of the Department of Surgery at Mount Sinai School of Medicine observe: “African-Americans have historically donated significantly fewer cadaver kidneys than they have received. They have benefitted from Caucasian organ donation.”

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Donation is a gift of life that transcends racial score-keeping, but it is still important to look closely at the numbers when bias in the allocation of kidneys is alleged.

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