Blacks Getting Short Shrift? : Study Suggests Racism May Affect Health Care

Black Americans, who on average live shorter and less healthful lives than whites, may be getting short shrift from medicine in two key areas--high-tech procedures for treating heart disease and drug testing to determine which pharmaceuticals work and for whom.

Blacks hospitalized with heart disease receive proportionately fewer bypass graft surgeries and certain other highly specialized procedures than whites, according to a study published today in the Journal of the American Medical Assn. One expert suggested Thursday that the causes range from economics to subtle forms of racism.

Blacks are also under-represented in clinical trials of new drugs, according to a second study in the Journal. The author of that study said it may therefore be impossible to judge accurately the effects of many new drugs in blacks and other minorities.

Both findings add new evidence to what many researchers say is a continuing gap between black and white access to health care--a gap they say has contributed to strikingly higher rates of sickness and premature death among black Americans.

The reasons for many of the disparities are complex and not entirely clear: They may include differences in access to insurance, life style and genetic variables, researchers say. They may also reflect varying interactions between patients and physicians.

For example, despite current heart disease data, physicians may be slower to suspect heart disease in black patients, said Dr. Richard Cooper, a Chicago cardiologist and author of an upcoming study on heart disease treatment. He said they also may base decisions on what he called “social value.”

“Doctors internalize the social ethic that some (people) are worth more than others,” speculated Cooper, whose nationwide study is to be published this spring. Because of limited resources, high-quality care may be apportioned partly on that basis, he said.

However, Dr. Mark B. Wenneker, a research fellow at the Harvard School of Public Health and co-author of the heart disease study in the Journal of the American Medical Assn., said it is not yet possible to explain why blacks are receiving fewer high-tech heart procedures than whites.

“I think it’s important to understand that this may actually reflect the fact that white patients may be receiving too many procedures,” Wenneker said Thursday in a telephone interview. “We just don’t know.”

Wenneker’s group examined the records of all patients admitted in 1985 to Massachusetts hospitals for circulatory diseases or chest pain. The group was concerned that growing health-care competition might be reducing access to services, particularly among disadvantaged groups.

They found that white patients were more than twice as likely as blacks to undergo coronary bypass graft surgery. They were also more than twice as likely to undergo angioplasty, in which narrowed blood vessels are widened using a fine catheter and a balloon.

Whites were more than a third more likely to receive cardiac catheterization, used to examine the heart and blood vessels. In the case of all three procedures, the researchers took into account such factors as age, diagnosis, insurance and income.

The researchers also considered whether whites might be sicker than blacks. But they found that available evidence suggests that blacks have the same or even greater rates of coronary disease and a higher prevalence of risk factors such as hypertension and diabetes.

“This study suggests that racial inequalities exist in the provision of cardiac care in Massachusetts,” they concluded. While they said race alone may not account for those discrepancies, they said it “does seem to be important.”

Meanwhile, in the same issue of the Journal, another researcher found that blacks are under-represented in drug trials--studies that enable drug companies and doctors eventually to tailor therapies and dosages to individual patients.

People of different races--as well as different sexes and age groups--respond differently to some drugs. Without examining those variations, due to differences in metabolism and perhaps in the disease being treated, the possibility of dangerous reactions may go undetected.

Craig K. Svensson, an assistant professor of pharmaceutical sciences at Wayne State University in Detroit, studied black participation in 50 recently published drug trials. Such studies are required before any drug can be approved for marketing in the United States.

Only 10 of the studies provided data about the race of the participants. The authors of 25 more provided the information on request. Of those 35 studies, only 20 included any black subjects. Most studies had a lower proportion of blacks than in the general population.

Furthermore, even though blacks and whites respond differently to drugs for hypertension, the researchers examined those differences in only one of the 13 hypertension studies for which racial data was available.

In another study examining whether sickle-cell anemia affected a person’s ability to absorb and distribute a new sickle-cell drug, Svensson found that the researchers compared a group of blacks with the disease to a control group composed almost entirely of whites.

Theories Offered

“It doesn’t make sense,” Svensson said in an interview, referring to the fact that sickle-cell anemia occurs largely in blacks. “Because you’re not going to treat white subjects with an anti-sickling compound.”

Svensson offered several theories for why blacks may be under-represented in drug trials. Among them, he said, are that blacks may not be reached by current advertising for clinical trials. They may also respond differently to recruitment by researchers--most of whom, Svensson said, are white.

He and Dr. Elliot S. Vesell of Pennsylvania State University, who has studied under-representation of women in trials, said researchers may enlist white men because it is easier to document a drug’s effects when studying a homogeneous group of people.

In the same issue of the Journal, other researchers reported that blacks continue to lag well behind whites in both overall health and access to medical care.

For example, black patients with cancer, heart and cardiovascular disease and diabetes are significantly more likely to die of those diseases than white patients. The infant mortality rate for blacks is twice as high as it is for whites, according to federal figures.

Life expectancy at birth for blacks is what it was for whites 30 years ago.

“One would have expected that many of these access problems . . . would have (improved) by now,” said Howard E. Freeman, a UCLA sociologist and co-author of a survey of access to health care. “There are a lot of people who are very impatient with the pace of change.”