"Of all the forms of inequality, injustice in healthcare
is the most shocking and inhumane."
—Martin Luther King Jr.
The United States is currently challenged by a striking health inequity that stymies the wellbeing of vulnerable populations.1,2 Individuals who are socioeconomically disadvantaged, belong to traditionally underserved ethnic minorities or stigmatized groups, or live with a disability are consistently the least healthy.3 US health disparity is alarming not only in magnitude but also to the degree to which it has persisted over time. In 1980, the relative IM risk of an African American child compared to a white child was 2.04.4 In 2000, the comparative risk had risen to 2.46.5 The crippling disparities in health which exist in the shadows of American wealth speak not to a lack of resources, but to a fundamental lack of concern for traditionally underserved communities. While health disparity is a complex issue, contributing factors can be isolated. Scholars place barriers to health equity into one of two distinct categories: structural barriers and contextual barriers.
Structural contributors to health disparity are the reason why zip code and income have become powerful predictors of health and life expectancy. Simply by being born into the wrong neighborhood, an individual can have an increased likelihood of suffering from heart disease, asthma, low birth weight, diabetes, obesity - and the list goes on. The reason for this has been attributed to a variety of non-biological factors known as social determinants of health. Social and environmental factors that affect health are complex and not always obvious. Examples include food deserts, urban blight, toxins associated with poor housing conditions and a lack of public transportation. While the health of all disadvantaged populations is influenced to some degree by harmful structural factors, minorities are disproportionately affected. This is in part the result of institutional racism, such as residential segregation, which has functioned to maintain historical racial inequities in health and socioeconomic status. Due to the large degree to which the health of disadvantaged populations is crippled by adverse environmental and socioeconomic factors, medical curricula must extend beyond biology to provide future physicians with an understanding of the social context within which they will work. This non-biologic component of medical education will be essential to ensure that the next generation of physicians will be prepared to serve not only as competent care providers, but also as advocates for necessary change.
Contextual barriers contribute to suboptimal patient-physician interactions. Studies have identified two major factors that prevent minority, poor, or stigmatized patients from receiving good care: physician bias (conscious or otherwise) and a lack of understanding amongst physicians of vulnerable populations, particularly with regard to the social and environmental factors that affect their health. The Institute of Medicine, in their 2002 report Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care acknowledge that “although a myriad of sources contribute to these disparities, some evidence suggests that bias, prejudice and stereotyping on the part of healthcare providers may contribute to differences in care.” 6 In an eye opening study, primary care physicians described factors that impair them from effectively caring for poor patients as being the presence of "prejudice in the back of my head" as well as a "lack of knowledge of how to interact with socioeconomically disadvantaged persons."7 In addition, multiple studies have found US resident physicians to possess a low level of knowledge regarding issues relevant to medically underserved populations as well as health and healthcare disparities. 5, 6 Together structural and contextual barriers to health serve almost as a one-two punch. Patients who get sick in toxic communities arrive at the hospital only to receive suboptimal care from physicians. If this trend is to be reversed, medical education must provide a space for students to develop both an understanding and empathy for the patients who will be in greatest need of their help as physicians.
- Meyer, P. A., Yoon, P. W., & Kaufmann, R. B. (2013). CDC Health Disparities and Inequalities Report-United States, 2013. MMWR supplements, 62(3), 3-5.
- National Healthcare Quality and Disparities Report (2016). US Department of Health and Human Services.
- Fiscella, K., & Williams, D. R. (2004). Health disparities based on socioeconomic inequities: implications for urban health care. Academic Medicine, 79(12), 1139-1147.
- Alexander, G. R., Wingate, M. S., Bader, D., & Kogan, M. D. (2008). The increasing racial disparity in infant mortality rates: composition and contributors to recent US trends. American Journal of Obstetrics & Gynecology, 198(1), 51-e1.
- CDC 2013 Period Linked Birth/Infant Death Data Set
- Institute of Medicine. 2003. Unequal Treatment: Confronting Racialand Ethnic Disparities in Health Care. Washington, DC: The National Academies Press.
- Loignon, C., Boudreault-Fournier, A., Truchon, K., Labrousse, Y., & Fortin, B. (2014). Medical residents reflect on their prejudices toward poverty: a photovoice training project. BMC medical education, 14(1), 1050.
- Marshall JK, Cooper LA, Green AR, et al. Residents’ attitude, knowledge, and perceived preparedness toward caring for patients from diverse sociocultural backgrounds. Health Equity. 2017;1:43–49.
- Wieland ML, Beckman TJ, Cha SS, et al. Resident physicians’ knowledge of underserved patients: a multi-institutional survey. Mayo Clin Proc. 2010; 85:728–733.