The Institute of Medicine Report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, found that racial and ethnic minorities receive lower quality of care than whites. The report identified racial prejudice and differences in the quality of health plans as possible reasons why even insured minorities receive worse care, thus contributing to higher death rates from cancer, heart disease, diabetes, and HIV/AIDS. Minorities are more likely than whites to be enrolled in lower-end insurance plans that impose stricter limits on medical services. But even when their insurance and incomes are the same, disparity persists often because minority patients are less likely than whites to have a long-lasting relationship with a primary care physician. Racial bias also plays a role. A study of major medical centers in New York State found that African-Americans were 37 percent less likely to undergo angioplasty and other heart procedures than whites. In 90 percent of these cases, the doctor had not recommended it. After interviewing doctors, the researchers found "classic negative racial stereotypes," such as the assumption that black patients would be less likely to participate in follow-up care. The entire report can be found at http://www.nap.edu/books/030908265X/html/.

Dr. Satcher challenged both the individual and society to create healthy lifestyles. The individual must take responsibility for leading a healthy lifestyle. Dr. Satcher emphasized physical activity, which offers benefits such as improved mental health, a lower the risk of death, and a de-creased risk of many types of cancer, in addition to preventing or reducing the problems associated with overweight and obesity. He also discussed personal responsibility for avoiding tobacco and substance use, and behaving in a sexually responsible manner. However, he stated that there is a community responsibility as well. He gave the example of schools that are eliminating physical education programs, but adding more soda and snack vending machines. This hinders students from forming positive physical activity habits, and encourages weight gain and obesity.

According to Dr. Satcher, the "points of attack" for achieving a high quality of health and eliminating disparity include access to care, improved quality of care, lifestyle enhancement, improving environmental quality, and establishing a balanced research agenda. Dr. Satcher identified several "settings for action." Families and communities play important roles in encouraging a healthy lifestyle and providing safe locations for physical activity. Schools and the work place offer excellent opportunities for advancing knowledge of a healthy quality of life. The media is another valuable tool for communicating with and educating the public about the health issues facing Americans. A very important setting for action is within the health care system itself, where elements crucial to eliminating disparities include educating doctors, improving accessibility to care, and finding ways to provide health insurance to all Americans. Over 400 private, state, environmental, substance abuse and mental health departments are using the Healthy People 2010 objectives to improve the nation's health.

Dr. Satcher ended his talk by quoting John Gardner, the former US Secretary of Health, Education, and Welfare - "Life is filled with golden opportunities carefully disguised as irresolvable problems."

*In 1932, the Public Health Service, working with the Tuskegee Institute, began a study of nearly 400 poor black men with syphilis from Macon County, Alabama. The purpose of the study was to follow how the disease spreads and kills. The subjects were never told they had syphilis, nor were they ever treated for it. For participating in the study, the men were given free medical exams, free meals and free burial insurance. Even after penicillin became a standard cure for the disease in 1947, the medicine was withheld from the men. The experiment lasted until 1972, when public health workers leaked the story to the media. By then, dozens of the men had died, and many wives and children had been infected. In 1973, the National Association for the Advancement of Colored People (NAACP) filed a class-action lawsuit and a $9 million settlement was divided among the study's participants. Free health care was given to the men who were still living, and to infected wives, widows and children. - Source: Alex Chadwick, NPR's Morning Edition

Deborah Washington, RN, Director of Diversity for Patient Care Services, followed Dr. Satcher by asking how we can ensure that MGH is not enabling the statistics Dr. Satcher presented? She provided examples of how MGH is working to provide a diverse environment free of disparity in its access to health care by referencing the National Standards for Culturally and Linguistically Appropriate Services in Health Care, as established by the US Department of Health and Human Services Office of Minority Health.

Standard 1 involves the patient and provider encounter. MGH has sought to ensure that all patients receive respectful care by offering the Culturally Competent Care Curriculum, Nursing Grand Rounds, the Office of Patient Advocacy, and encouraging patient feedback.

Standard 2 addresses Staff Diversity. MGH has implemented several programs to improve diversity among the patient care staff. In addition to an overall nursing shortage, Ms. Washington stated that in America, only 10 percent of nurses are non-white, so there has been an effort to attract nurses of various ethnicities. In addition, there is the Foreign-born Nurse Program which encourages care providers from foreign countries with nursing degrees to work toward their American nursing licenses. The Pipeline Program works with schools such as UMass to provide nursing students an opportunity to work part-time at MGH toward a full-time position upon completion of school. There are also Employee Service grants which provide tuition reimbursement to those who work in the Service departments at MGH but wish to become patient care providers.

Standards 4, 5, 6, and 7 deal with Language Assistance. The Office of Interpreter Services provides interpreter assistance to patients. The Blum Patient and Family Learning Center offers patients information in a variety of languages to help them learn about their health and illness.

Standards 8 and 9 deal with Organizational Accountability. MGH has worked to create an awareness of racial and ethnic sensitivity within the hospital through the creation of the MGH Diversity Committee, the Patient Care Services Diversity Committee, and the Office of Multicultural Affairs.

Joseph Betancourt, MD, MPH, Senior Scientist, Institute for Health Policy, and Program Director for Multicultural Education, spoke next. He explained that the identification of racial and ethnic disparities emerged in the late 1990s, and the Institute of Medicine was asked to evaluate the situation and report their findings. This led to the report Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, mentioned by Dr. Satcher.

MGH's response to the findings in the Report on Unequal Treatment includes the following actions:

• Increasing awareness of disparities: Grand Rounds, lecture series
• Improving Health Workforce Diversity: Multicultural Affairs office - minority recruitment effort
• Facilitating Interpreter Services
• Provider Education in Cultural Competency: Cross-cultural curriculum required for internal medicine residents
• Supporting use of community health workers
• Conducting research on disparities

Challenges still facing MGH, include increasing data collection, patient education, and the creation of evidence-based guidelines for quality improvement. He concluded by emphasizing the importance of collecting MGH data and forming partnerships across departments.

For further information about Healthy People 2010, please visit the program's website.

12/2002