WHY DO RACIAL AND ETHNIC HEALTH DISPARITIES PERSIST? Racial and ethnic health disparities are the product of a complex mixture of racism, classism, the systematic exclusion of people of color from educational opportunities, the systematic exclusion of people of color from economic opportunities, and a criminal justice system which was founded on a narrative of superiority and inferiority in terms of skin color.

WHAT IS THE GENESIS OF RACIAL AND ETHNIC HEALTH DISPARITIES? Dr. Richard Allen Williams, a past President of the National Medical Association stated that “In order to better understand racial and ethnic health disparities, we must dismantle the structural factors which explain why people of color are less healthy.”

The Health Policy Institute of Ohio published in 2004, the Health Disparities Framework, which separates healthcare factors into 3 divisions: Health – before care which is what we now call the social determinants of health; Access to Care; and Health Care Delivery. Arguably, the social determinants are the most important factors in the health disparities framework because these determinants set the precedent for access to healthcare, access to health care delivery, and ultimately patient outcomes.

The Wealth Gap:
In the United States the median household income for white Americans is $89,632; for African-Americans it is $58,985; for the Hispanic/Latinx it is $68,319. The Urban League of Southwestern Ohio reports that the average income for black families in Hamilton County is $29,989; for white families it is $62,217. The unemployment rate for black Cincinnatians is 2-3x times the unemployment rate for white Cincinnatians. The poverty rate for Cincinnati by race, as reported by the U.S. Census Bureau/American Community Survey 2017, shows a poverty rate of 39.6% for Black Cincinnatians and a poverty rate of 17.5% for White Cincinnatians. The poverty rate for the Hispanic/Latinx population is 35.8%, and for Asians it is 31.5%. The poverty rates for Cincinnati are greater than the national rates, and for cities with populations of at least 250,000, Cincinnati has the fifth highest poverty rate. Cincinnati, moreover, lags behind peer cities in the number of minority-owned businesses per 1,000 residents. Since 1983, the Cincinnati Enquirer has published the annual Deloitte 100 report of the 100 top private companies in the Greater Cincinnati region. I read the report every year. There have never been more than 3 African-Americans on the list in any year during the 34 years that I have lived in Cincinnati.

Home ownership is the foundation of wealth accumulation for the American middle class. In 2017, the American Community Survey in conjunction with data from the U.S. Census Bureau reported that the national home ownership rate in our country is 64%. For African-Americans the rate is 42%; it is 47% for the Hispanic/Latinx population. For the Native American/Alaskan Native population the home ownership rate is 58%, and for White Americans the rate is 72%. In Cincinnati, 33% of African-Americans are homeowners; 75% of white Cincinnatians are homeowners. Potential black home buyers face higher rejection rates than white home buyers REGARDLESS OF THEIR INCOMES. Credit standards make it more difficult to obtain a mortgage. Lenders say that African-Americans with solid incomes often have lower credit scores and less savings or family help available for a down payment. Redlining or denying loans to people in certain neighborhoods is a barrier to black home owner ship. Cincinnati has one of the 10 highest eviction rates in the country.

Structural inequalities in income, housing, jobs, and health care contribute to the racial and ethnic health disparities. The CDC asserts that racial residential segregation is linked with a variety of adverse underlying conditions, and these conditions can also increase the likelihood of severe illness from COVID-19. African-American and Latinx communities have been disproportionately impacted by the pandemic, and a disproportionate number of people of color are of low income. Approximately 25% of employed Latinx and black American workers are employed in the service industry jobs, as compared to 16% of non-Hispanic whites. 16% of Latinx workers in the U.S. can work from home; 19.7% of black workers can work from home. 29.9% of white workers can work from home. In Cincinnati, 16% of black workers who earn less than $15,000 per year rely on public transportation, where they cannot social distance. In comparison, only 4% of white workers in the same income bracket rely on public transit, as reported by the Urban League of Greater Southwestern Ohio in the report “The State of Black Cincinnati 2015: Two Cities.”

A quality education is still seen as the ticket to an enhanced quality of life and a promising future in our country. The profile of U.S. Education American public schools shows that:
White Americans comprise 60.4% of the total U.S. population and 47.6% of U.S. public school students.
African-Americans comprise 13% of the population and 15.2% of the U.S. public school students.
The Hispanic/Latinx comprise 18% of the population and 26.7% of the U.S. public school students
The Native American and Alaskan Natives comprise 1% of the population and 1% of the students.
The Hawaiian Island/Pacific Islanders comprise 0.4% of the population and 0.4% of the students.
However, more than 70% of U.S. public school principals and teachers are white. African-Americans comprise only 6.7% of public school teachers and 10.5% of public school principals. 9.3% of public school teachers and 8.9% of public school principals are Hispanic/Latinx. Native American/Alaskan Natives comprise 0.5% of public school teachers and 0.7% of principals. Hawaiian Native/Pacific Islanders comprise 0.2% of public school teachers and 0.2% of the principals.

In the state of Ohio the overall graduation rate is 84.2%. For Black students the graduation rate is 68.6%, and for white students the graduation rate is 88.2%. For Hispanic/Latinx students the graduation rate is 73.6%; for Asian students the rate is 88%. The Urban League of Greater Southwestern Ohio reported in 2015, that 63% of the students in the Cincinnati Public School system are African-American, and 74% of these students come from economically disadvantaged families. Being poor means that these students have fewer experiences that enhance their development and get them ready for school. Moreover, students of color and students with disabilities are all at a high risk for suspensions and expulsion. The Council for Great City Schools reports that disciplinary disparities begin as early as preschool. Students who are suspended or expelled are more likely to be truant, are less likely to achieve, and more likely to drop out, and end up with delinquency and criminal records.

Associate Professor Kerry Ard of Ohio State University concluded that, “Black Americans are twice as likely to be exposed to air pollution and more likely to be exposed to the most toxic pollution. Even African-Americans with higher incomes are exposed to more toxic air than white Americans with lower incomes.” Researchers at Harvard University and the University of Memphis also concluded that long-term exposure to air pollution increases vulnerability to the very serious states of COVID-19. Environmental racism as defined in the report “Race and Health in the United States,” as the intentional or unintentional targeting of minority communities for the siting of polluting industries such as toxic waste disposal, through the race-based differential enforcement of environmental rules and regulations and exclusion of people of color from public and private boards and regulatory bodies, resulting in greater exposure of the community to pollution. RD Bullard writes that a growing body of evidence reveals that people of color and low-income persons have borne greater environmental and health risks than the society at large in their neighborhoods, workplaces, and playgrounds. Where we live, work, learn, and play impacts our health.

Dr. Richard Allen Williams has stated that “it is estimated that 70% of the minority population do not know what ails them and why then need to be concerned about their health.” He contends that “by raising awareness of medical issues and actually educating our people about them, we can increase health literacy among our citizens.” African-Americans have higher rates of mortality than does any other racial or ethnic group for 8 of the top 10 causes of death. U.S. Latinx have higher rates of death from diabetes, liver disease, and infectious diseases than does the rest of the U.S. population. Native Americans suffer from higher rates of diabetes, tuberculosis, pneumonia, influenza, and alcoholism than does the rest of the U.S. population. As healthcare providers, and especially as underrepresented minority physicians, our mission is to educate and empower our patients and help them to understand that they must become active participants in the management of their healthcare.

Access to healthcare determines the quality of health care delivery which a patient receives. In “How Racial Hierarchy Kills,” the noted writer Khiara M. Bridges asserts that “if people of color do not go to the doctor as often as their white counterparts, it is likely because they do not have health insurance or there are not quality health care providers available to them.” In its report on diversity in medicine in 2018, the American Association of Medical Colleges(AAMC) reported that 56% of all active physicians self-identified as White, and 5% self-identified as Black. 5.8% of active physicians self-identified as Hispanic/Latinx. 17% were Asian, less that 1% were Native American/Alaskan Native, and less than 1% self-identified as Hawaiian Native/Pacific Islanders.
The percentage of full-time U.S. medical school faculty was 64% White, 19% Asian, 3.6% Black, 5.5% Hispanic/Latinx, < 1% Native American/Alaskan Native, and < 1% Hawaiian Native/Pacific Islander. When the numbers of residents or doctors in training were reviewed, it was noted that this trend continues. African-Americans comprised 5.7% of residents in training, and Hispanic/Latinx residents comprised 7.6% of the total. For acceptance into medical school in 2018, 49.8% of the students were White; 7.1% were Black. 22% of the students accepted into medical school were Asian, and 6.2% were Hispanic/Latinx. Native American/Alaskan Native students comprised 0.1% of medical school students accepted, and 0.2% were Hawaiian Native/Pacific Islanders. Racial/ethnic concordance between physicians and patients improves patient satisfaction and ultimately patient outcomes. United States medical schools must train more underrepresented minority physicians. The CDC reports that compared to white Americans, the Latinx are almost three times as likely to be uninsured, and African-Americans are almost twice as likely to be uninsured. For 85% of the visits to private physician offices, the cost is paid by private insurance or Medicare. Private office visits by African-Americans are less than any other demographic group, but Emergency Department visits by African-Americans are higher than any other demographic group. The U.S. healthcare system is geared toward serving English speakers, and especially for Latinx patients, miscommunication is common. This can lead to mistrust of doctors and the health system. HEALTH EQUITY: Our challenge is to achieve health equity. In contemplating how this can be done, we must consider that the life expectancy for African-Americans and Native Americans is the lowest of all demographic groups. One of every three Black men can expect to be incarcerated in his life. In the state of Ohio, Black men comprise nearly half of the prison population. The state of Ohio spends $26,509 annually to care for inmates, but the state of Ohio spends only $12,000 annually for each public school student. Nationally, the infant mortality rate for Black babies is twice that of White babies. The maternal mortality rate for African-American women is three to four times that of women who are white or Hispanic/Latinx. In Hamilton County the infant mortality rate for Black babies is three times the rate for White babies. The preterm birth rate for African-American women is also two times that of women who are white. The Robert Wood Johnson Foundation states that “health equity means that everyone has a fair and just opportunity to be as healthy as possible. This requires removing obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education, and housing, safe environments, and health care.”