Zero tolerance for racial and ethnic disparities in health care is a standard that has been widely endorsed in medicine, as the AMA and the Health and Human Services Dept. joined in doing some three years ago. Yet as a physician serving on the front lines — I practice primary care in the inner city — I find that these disparities continue unabated.
These disparities are an integral part of a long history of discrimination. In addition, certain racial and ethnic populations carry a disproportionate share of major chronic disease burdens such as diabetes, asthma, hypertension, congestive heart failure, HIV and hepatitis. Contributing to the problem are various barriers to care — linguistics, culture, socioeconomics and health illiteracy — which cannot be ignored if care is to be effective.
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Disparities may present as unequal treatment; that is, the unequal allocation of resources to individuals or communities. Or they may present as the “disparate impact” of various health care infrastructures and policies that, while not obviously discriminatory — “facially neutral” as lawyers would say — are especially detrimental for certain racial and ethnic populations.
This disparate impact can be both subtle and pervasive, as the practice of primary care in the inner city illustrates. Primary care is the window on the health care system for these at-risk patients, the foundation of the care delivered to them and their gateway to specialty care. As elsewhere, the vast majority of patients — over 90% of diabetics, for instance — are cared for by primary care physicians.
