Multicultural Medicine and Health Disparities
http://www.100md.com
《新英格兰医药杂志》
Intermittently, but all too fleetingly, the American public focuses attention on the connections among race, ethnic group, social class, poverty, marginalization, and access to health care and other resources and recognizes the effect that these factors have on the health of minority populations. This awareness was apparent most recently in the aftermath of Hurricane Katrina, which both symbolized and exposed the realities of life and death in New Orleans's black Ninth Ward before the storm. However, the same story was told in the 1940s, in chapters on race and health in Gunnar Myrdal's An American Dilemma (New York: Harper & Brothers, 1944); in the 1960s, when Michael Harrington's The Other America: Poverty in the United States (New York: Macmillan, 1962) and the Civil Rights Movement laid bare the truths of hunger and sickness in the rural South and in northern urban ghettos; and in the 1980s, with the publication of the Report of the Secretary's Task Force on Black and Minority Health (1985) by the Department of Health and Human Services. Yet during the same time span — from 1940 to 1998 — a careful analysis of age-adjusted risk differentials between blacks and whites counted 4.4 million premature deaths among blacks. This situation has been, in the words of one observer, a constant hurricane blowing through the black population; the health status of blacks in 2000 approximated that of whites — in 1960. Worse, in the United States since 1945, there has been no sustained national improvement regarding black–white disparities in overall age-adjusted mortality or in overall life expectancy at birth. Worse still, there is a gathering storm: the likelihood of similar losses among Hispanics, Native Americans, and some Asian subgroups in the United States. When combined with blacks, these groups will constitute a near majority of the U.S. population by 2050.
Former Surgeon General David Satcher and Rubens J. Pamies, the editors of Multicultural Medicine and Health Disparities, have set out again to document and explore the causes of these problems and, most important, to propose programs and policies as pathways to equity. To do so, they have recruited 81 scholars — epidemiologists, demographers, clinicians, health service researchers, behavioral scientists, and others — from more than 40 academic medical centers, government agencies, research institutions, foundations, and think tanks. The result is a book that is well documented, lucid, comprehensive, and easily accessible — owing in no small measure to an inspired use of tables and figures to summarize evidence. Despite some flaws, this book should be on the desks — not the shelves — of physicians, students of the health professions, policymakers, and legislators. It belongs next to the Institute of Medicine's landmark book on racial and ethnic disparities in the quality and comprehensiveness of health care, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (Washington, D.C.: National Academies Press, 2003).
Multicultural Medicine and Health Disparities is divided into three broad sections. The first, "Health-Care Disparities Across the Life Span," is a fresh and superbly documented presentation of the evidence — national, regional, and local — of disparities among different groups from pregnancy through childhood to end-of-life care. The second section, "The Disparate Burden of Disease," samples important categories such as cardiovascular disease, cancer, diabetes, HIV infection and AIDS, obesity, and mental health, and it includes topics less frequently covered in reviews of disparities. These topics include substance abuse, the prevention of injury and violence, and the management of pain. The final section, "Issues in Health-Care Policy and Delivery," focuses on core issues such as diversity in the health workforce and includes a sterling essay on the benefits of affirmative action in higher education by Jordan Cohen, president of the Association of American Medical Colleges. Vanessa Northington Gamble contributes a thoughtful review of the trust in (and distrust of) physicians and health care systems among minority groups. Three chapters that are based on clinical vignettes address "multicultural medicine" and cultural competence and — like most of this genre — range from the simplistic to the subtle.
Almost every chapter ends with a section on policy implications and recommendations, and here, this book is most uneven. Some chapters focus firmly on the social determinants of health status: racial segregation and concentrations of poverty and other risk factors in communities, unemployment, inferior education and housing, toxic physical and biologic environments, inequalities of income and wealth, and lack of social cohesion. Other chapters simply call for increased expenditures for a safety net for the health of minority populations. In the current climate, these chapters seem to be whistling past the graveyard of social responsibility for health, since federal and state authorities are slashing funding, eligibility, and benefits for Medicaid and other resources. In addition, many recommendations simply echo those of Healthy People 2010, which focuses almost exclusively on access to quality care and on lifestyle changes in its promise to "eliminate" disparities. However, since medical care accounts for only about 15 percent of the health status of a given population, and elegant studies of attributable risk indicate that lifestyle choices account for only 20 to 30 percent of the gap in health status between minorities and whites, this approach will not and cannot eliminate disparities. I wish this book had been more decisive and uniform in arguing that only real changes in socioeconomic distribution and race relations will suffice for that task. Nevertheless, the evidence that buttresses that argument is all found within these pages, and this valuable book should be widely read, studied, and recognized for what it is — an exploration of an ongoing American tragedy.
H. Jack Geiger, M.D.
City University of New York Medical School
New York, NY 10031
jgeiger@med.cuny.edu(Edited by David Satcher a)
Former Surgeon General David Satcher and Rubens J. Pamies, the editors of Multicultural Medicine and Health Disparities, have set out again to document and explore the causes of these problems and, most important, to propose programs and policies as pathways to equity. To do so, they have recruited 81 scholars — epidemiologists, demographers, clinicians, health service researchers, behavioral scientists, and others — from more than 40 academic medical centers, government agencies, research institutions, foundations, and think tanks. The result is a book that is well documented, lucid, comprehensive, and easily accessible — owing in no small measure to an inspired use of tables and figures to summarize evidence. Despite some flaws, this book should be on the desks — not the shelves — of physicians, students of the health professions, policymakers, and legislators. It belongs next to the Institute of Medicine's landmark book on racial and ethnic disparities in the quality and comprehensiveness of health care, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (Washington, D.C.: National Academies Press, 2003).
Multicultural Medicine and Health Disparities is divided into three broad sections. The first, "Health-Care Disparities Across the Life Span," is a fresh and superbly documented presentation of the evidence — national, regional, and local — of disparities among different groups from pregnancy through childhood to end-of-life care. The second section, "The Disparate Burden of Disease," samples important categories such as cardiovascular disease, cancer, diabetes, HIV infection and AIDS, obesity, and mental health, and it includes topics less frequently covered in reviews of disparities. These topics include substance abuse, the prevention of injury and violence, and the management of pain. The final section, "Issues in Health-Care Policy and Delivery," focuses on core issues such as diversity in the health workforce and includes a sterling essay on the benefits of affirmative action in higher education by Jordan Cohen, president of the Association of American Medical Colleges. Vanessa Northington Gamble contributes a thoughtful review of the trust in (and distrust of) physicians and health care systems among minority groups. Three chapters that are based on clinical vignettes address "multicultural medicine" and cultural competence and — like most of this genre — range from the simplistic to the subtle.
Almost every chapter ends with a section on policy implications and recommendations, and here, this book is most uneven. Some chapters focus firmly on the social determinants of health status: racial segregation and concentrations of poverty and other risk factors in communities, unemployment, inferior education and housing, toxic physical and biologic environments, inequalities of income and wealth, and lack of social cohesion. Other chapters simply call for increased expenditures for a safety net for the health of minority populations. In the current climate, these chapters seem to be whistling past the graveyard of social responsibility for health, since federal and state authorities are slashing funding, eligibility, and benefits for Medicaid and other resources. In addition, many recommendations simply echo those of Healthy People 2010, which focuses almost exclusively on access to quality care and on lifestyle changes in its promise to "eliminate" disparities. However, since medical care accounts for only about 15 percent of the health status of a given population, and elegant studies of attributable risk indicate that lifestyle choices account for only 20 to 30 percent of the gap in health status between minorities and whites, this approach will not and cannot eliminate disparities. I wish this book had been more decisive and uniform in arguing that only real changes in socioeconomic distribution and race relations will suffice for that task. Nevertheless, the evidence that buttresses that argument is all found within these pages, and this valuable book should be widely read, studied, and recognized for what it is — an exploration of an ongoing American tragedy.
H. Jack Geiger, M.D.
City University of New York Medical School
New York, NY 10031
jgeiger@med.cuny.edu(Edited by David Satcher a)