‘Feet to the fire’: Addressing racial disparities in medicine requires ‘continuous’ work
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Addressing the racial disparities that continue to plague health care requires “continuous” work, as well as holding certain providers’ “feet to the fire,” said a presenter at the 2022 Association of Women in Rheumatology annual conference.
“We know that disparity exists,” Alvin F. Wells, MD, PhD, director of the rheumatology and immunology center and adjunct assistant professor at Duke University Medical Center, told attendees at the hybrid meeting. “The issue is how do we bridge that gap.”
Although Wells acknowledged that multiple factors — including religion, race, ethnicity, socioeconomic status, gender, mental health or cognitive disability, sexual orientation and geographic location — can lead to health disparities, he focused his talk largely on race.
“I am going to make some of you uncomfortable,” he said. “I really want to challenge you. We are near the end of 2022 and we are still talking about disparities. They definitely still exist in health care.”
In demonstration of this point, Wells walked through data sets going back to the 2000s demonstrating that health disparities exist across disease states.
For example, data back to 2007 showed that patients from underrepresented populations often continued to experience higher rates of rheumatoid arthritis disease activity or were treated with prednisone and NSAIDs for longer before transitioning to a biologic therapy.
“In 2007, we had amazing drugs,” he said.
However, many patients from underrepresented populations were effectively given the same message: “You can’t have them.”
Mortality rates in systemic lupus erythematosus have declined in recent years with the advent of drugs like mycophenolate mofetil (MMF), rituximab (Rituxan, Genentech) and belimumab (Benlysta, GlaxoSmithKline), but data presented as recently as last year’s American College of Rheumatology Annual Meeting showed that Black patients continue to demonstrate higher rates of comorbidities and physical limitations.
For Wells, a key issue is that non-rheumatologists are not adequately addressing cardiovascular or renal disease in these patients, nor are they referring them to rheumatology or prescribing effective medications.
“We should be holding primary care doctors’ feet to the fire,” he said.
There is a similar situation in psoriatic arthritis, where comorbidities like hypertension, diabetes and gout are more prevalent in Black patients compared with whites.
Meanwhile, in osteoarthritis, Black patients are less likely to have a knee replacement, according to Wells. Moreover, when they do get a knee replacement, they are less likely to undergo physical therapy, he added.
According to Wells, achieving equity is “continuous” process, and will require ongoing effort at multiple levels.
Starting with educating residents, Wells suggested that omitting the patient’s race in case reports may minimize stereotypes associated with certain population groups.
“When I show a case of a 35-year-old Black man, it is automatically assumed that he is on drugs or has sickle cell,” he said.
Such assumptions can impact how students think about their patients once they become practitioners.
Another solution Wells discussed pertains to “pharmacy deserts,” or regions of the country that lack a sufficient number of drug stores to serve the population. Of particular concern is that this issue is not limited only to rural areas.
“In some cities, there is a Walgreens on every corner,” he said. “But it is not the same in every city.”
Chicago, Philadelphia, Boston and Los Angeles all have pockets where patients do not have easy access to pharmacies, according to Wells.
A solution, Wells suggested, would be to have delivery services or drones drop prescriptions at a patient’s door no matter where they live.
Corporations can play a role in promoting equity, as well, according to Wells. He noted that Novartis has a program to promote careers in science and medicine among high school and college students of color, while a Janssen program promotes limb-sparing therapy in patients with peripheral artery disease.
Additionally, Wells described what he called “Alvin’s provocative idea,” which is to simply give certain individuals $1,000 every month for out-of-pocket medical costs, covering everything from a cane for OA to bus fare for doctor appointments.
For another solution, Wells challenged attendees to stop thinking about the cost of therapies. Doctors should be doing everything they can to assist patients who face disparities to acquire their medications, whether that means writing letters, getting them into clinical trials or linking them to assistance programs.
Ultimately, the goal of every physician should be to give every patient the best care and the best treatments, regardless of their socioeconomic status or demographic factors.
“Who told a doctor you are the steward of which drug a patient can afford or not?” he said. “Ask yourself: Is my patient worth it?”
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Wells A. Keynote Address: Bridging the Gap to Equity. Presented at: AWIR National Conference; August 18-21, 2022; Hilton Head Island, South Carolina (hybrid meeting).
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