the work force issue has been touched on, our health care work force is not representative of minorities in the general population. hispanics comprise 12 percent of the population but only 2 percent of registered nurse and 3-and-a-half percent of physicians. similarly, african-american constitute 12 percent of the population, but only 5 percent of physicians, 9 percent of registered nurses and only 4 percent of dentists. in the last ten years the percentage has actually dropped in several key areas while slightly increasing in some other areas. .. medicine report on

equal treatment the increasing need for diversity. first, underrepresentative minority healthcare professions are significantly more likely to serve in medically underserved communities which included disadvantaged areas. patients are more likely to seek care from physicians of their own race or ethnicity and report being more satisfied in doing so. and third, minorities considering healthcare profession are more likely to pursue a field where they see minority role models. finally, the reason concerning medical research. mieshts are more likely to participate in research studies when the research is conducted by a healthcare provider of the same ethnic group. subsequently, underrepresentative minority healthcare professions are more likely to have healthcare interest when minorities are affected to help solve the mysteries why certain conditions disproportionately affect and

have poor outcomes on minorities. they see firsthand the various affecting the communities and their families and become interested in learning more about those diseases and outcome. studies are vital to understand why certain ethic groups are affected by disease and treatment. that is why i think it's essential for us to collect racial datas for minority health so we can understand the disease outcomes. it's been mentioned mortality, morbidity incidents. the u.s. care system has been very good if you're healthy. unfortunately, that's not the case for many individuals. despite the overall improvement in the u.s. population, racial and ethnic minorities experience high rates of morbidity and mortalities than nonminorities. it's proven by looking at life expectancies. african-american have shorter life at 66 years than white men on average will live to 74 and compare that to the american indians where in some areas are expected be to live if their mid-50s. the life expectancy gap that

between white and african-american males have not changed significantly in the past 40 years. even though our country can top major health and technological advances in the 60 years, african-american mortality rate is 1.6% higher than whites and this is identical to what it was in 1950. infant mortality is just as dismal. 2.5 and 1.5 times higher than whites. examining the prevalence of certain disease and condition and racial ethnic minorities we have further evidence of health disparities. african-americans have the highest rate of mortality heart disease and hiv diseases. if you look at hiv rates it's reaching epidemic proportion. more than 80% women who have been diagnosed with hiv or aids has been african-american or hispanic. african-american women have higher diabetes, liver disease and hispanics are expected to die more from diabetes which

modern medicine can now treat and manage adequately. hypertension in african-american lead to 80% stroke mortality rate, 50% rates of disease and 32% higher rates of renaturl disease. when we initially look at these datas we thought access to care was the suspected reason, however, even in veterans hospitals where access is not as much of an issue, major health disparities continue to exist. studies have shown that physicians are less likely to refer african-american african-american forbes cardiac catheterizations. and current theories on cardiovascular disparities is racial discrimination in treatment, genetics, environment and demographics. there are new theories emerging about the health disparities. first there is epigenetics or

changes in the dna by consistent exposures from diet to stress that can be passed from one generation to next. it underscores the cumulative effect of poor socioeconomic conditions, discrimination and inequality of education of opportunities. the second theory is the owl static load which the body experienced biological changes in response to stress, cortical tropic a releasing home which is found to be higher than those who experienced prolonged period of stress suggesting years of feeling unequal or experiencing discrimination be eventually lead to worsening cardiovascular health. the current economic situation is having a detrimental. fewer prescription drugs are being filled. the concern is that individuals being successfully maintained healthy blood pressures and other cardio vask conditions with medication may no longer be able to afford these medications which will result in higher blood pressure, increased in stress, hypertension and a number of other dangerous

conditions. in the near future we may see a shift with health medicine that emerges emergency room treatment at a much higher cost. the disproportionate burden of health disparities has been well documented. there's several reports contributing factors socioeconomic, racism, discrimination, limited access and the quality of service being provided. patient and provider behavior factors also are a factor. it compound a problem and create a cycle of problem. despite increasing care in immunization and it's significantly get worse or remain static. it means having substandard housing and fewer tujts for higher education, less insurance coverage limited access to healthcare. the environmental health risk includes anything from air quality, water quality, soil contaminates as well as other pollutants tend to be more prevalent in low socioeconomic

communities and low sociogroups often live in more segregated areas where there's more poverty and more drug and alcohol abuse. missing from these environments are green space, access to healthy food, job opportunities and access to healthcare. more than any other racial group african-americans tend to live in segregated neighborhoods even when you factor in income level. some major urban areas in the united states are segregated as they were back in -- before civil rights era and in apartheid era south africa. two third americans would have to relocate for a random distribution of black and white households in america. individuals living in segregated areas do not have resource to transfer wealth to the next generation. kids inherit a lifetime of poverty, a can la of educational opportunity and typically a lifetime of poor health. just a few words about the educational inequality.

low-incomed, segregated areas of communities have a lower tax base, less ability to support education as a result racial and ethnic minorities have fewer educational opportunities, fewer role models. they tend to limit their goals to low-paying and some cases hazardous occupation. for many minority children other expectations of them are set so low they never really reach their full potential. a recent report showed half of african-american children and 40% of hispanic children attended a high school where the dropout rate was close to 50%. this compared to only 11% of white attending those schools with those dismal statistics. >> dr. pamies, thank you very much. and we will continue during the q & a. dr. chandra. >> members of the commission, i'm a professor at harvard university's kennedy school of government and a fellow with the

dartmouth institute for health policy. thank you for inviting me for the information on how to improve healthcare for minority patients. we are all aware of the stubborn persistence of racial disparities in treatment over time even when patients are fully insured. many believe that the clinical encounter is the most pernicious source of these disparities. my main point this morning is that we are unlikely to make great strides in improving minority health like prioritizing action on this channel. the importance of the clinical chapter is dominated by other shortcomings such as the lack of access to high quality providers which are far more injurious to minority health. the racial disparities emanate principally from the clinical culture. embodies the provider treats two patients one white and one black differently. more precisely, differences in the clinical encounter may occur because there is explicit discrimination where a provider consciously withdraws valuable care from minority patients. this is the most mall feesant

disparities and perhaps one reason why there's so much interest in this mechanism but disparities may rise from implicit discrimination where a provider operating in a time sensitive environment make decisions that are detrimental to minorities, stereotyping is one of the discretion and it occurs when a provider uses a patient's race about the benefit of treatment. if, for example, african-american patients are on average less likely to be compliant than a physician may assume that her african-american patient is less compliant. such reasoning will worsen outcomes for that patient if he is different from the typical african-american patient and worsen outcomes for all african-americans if the stereotype about them is wrong. the bias from implicit discrimination is compounded by the presence of poor communication between providers and their patients. which may generate enormous psychological barriers to minority patients seeking care. finally, some researchers have

posited genetic or physiological differences between patients that affect the benefit of treatment of race while others have discounted such conclusions. given the discussion at the mechanism the question is to ask whether we established the role in affecting racial disparities in healthcare. answering this very simple question carefully poses an enormous and formidable empirical challenge. we would need to observe the same provider treating two patients with the same economic and social resources, physiology, clinical history, severity, preferences, compliance and future prognosis. these variables are routinely observed by providers treating patients but not by social scientists observing providers. the fact that multiple studies note minority patients get less care is often interpreted of pervasive bias in the clinical encounter it could just as well be interpreted as one of the shortcomings in all observational studies that focus on the clinical encounter.

second, because of patterns of neighborhood segregation, the same provider is rarely observed treating both black and white patients. and so what we have been calling prejudice in the clinical encounter is often a difference in neighborhoods referral patterns and the resources of providers that serve in these neighborhoods. this is an unfortunate confusion because improving neighborhood schools or changing referral patterns is not the same thing as reforming provider behavior inside hospitals and offices. researchers have made some progress on this challenge by using patient actors and implicit association tests where physician and the researchers studying them observed the same information in a laboratory setting. this is an intriguing area of academic research but it's still nascent of informing policy and legislation we do not know if the decisions made by self-selected physicians in these laboratory studies are representative of physicians who actually take care of minority populations. my main point today is to

elaborate on a new reason for racial disparities and care they are partially the difference of minority and whites receive their care. if different providers treat blacks and whites, then one reason for racial disparities in care is not only who you are, your race, but also where you live. both sources of disparities are injurious to minority health. the first type of variation which i call within provider are variation is the role of the clinical encounter. the second, which i called between provider variation relates less to race per se and more to geographic variations in the quality of treatment patterns for all patients. it contributes to racial disparities and treatment because minorities are more likely to be cared for by low-performing providers some large academic medical centers are an exception to this statement but the link between being treated at one of these centers and quality is by no means automatic. the difference where they are treated is insurance and lower socioeconomic status but

historical patterns in neighborhood segregation exacerbate this situation. confronted with these realities we should be extremely cautious in concluding that malfeasance and nonfeasance are the sole purview of the medical profession. so what does the evidence of the role of geography contribute to the disparities. the doctor shows the difference between whites and blacks and those providers are less clinically trained and have four resources. my collaborators have demonstrated 85% of all black heart attacks are treated in only 1,000 hospitals where 60% of whites receive their care in hospitals that treat no african-american patients. within hospitals we found, however, no disparities in effective care but found that patients who were admitted to hospitals that disproportionately served blacks had a risk adjusted mortality rate that was almost 20% higher than that of nonminority-serving hospitals. others have noted similar findings for the performance of neonatal intensive care units in

minority-serving hospitals. 40 years after the passage of the civil rights act, minority healthcare is both de facto, separate, and unequal. ironically, a closer cousin of this embarrassment which was segregated hospitals was the original motivation for title 6 legislation. the new focus on the geography of minority healthcare should not be viewed as taking attention away from reforming the clinical healthcare. if we could fully eliminate disparities within the clinical encounter, the healthcare of blacks would improve but still lag behind of whites because of differences of quality of care where the two groups receive care. for many of us, this is simply not good enough. because a small group of providers treat minority patients targeting quality improvements toward minority-serving providers will eliminate black/white disparities in care. it would help the minority and white patients but the gains would disproportionately accrue to minority care in such providers.

in the context of ambulatory care for diabetes by collaborators at dartmouth in improving the performance of the 500 largest minority-serving networks would improve minority healthcare more than the complete elimination of racial disparities within every provider in the united states. indeed, given the greater reliance on ambulatory care we would want to change title 6 to go beyond the reach of care that is delivered by office visits and managed care plans. finally in closing let me make one simple point. the determinance of racial disparities in health is not the same of determinance in racial disparities in healthcare. the principle determinance of health, are genes, behaviors, schooling, neighborhoods, economic circumstance. health is secondarily affected by healthcare but more likely to be influenced by prevention including the quality of

ambulatory care. of tertiary importance at the very end of the causal chain is the role of disparities in medical care. the quality of medical care matters much more than the disparity in the quality within it. so the 6 1/2-year racial gap in life expectancy in men and 4 1/2 racial gap for women which is larger when it accounts for the condition of life are unlikely to be affected by the focus on treatment disparities in the clinical encounter. the preoccupation with treatment disparities in the endgame simply misses the fact that minority patients find themselves confronting the endgame sooner than everyone else. thank you. >> thank you. dr. sadel. >> thank you for the invitation -- whoops, i address you today. >> move your microphone up a little. >> okay. >> they're not that sensitive. >> okay, thank you. is this better, all right. thank you for the invitation, chairman reynolds and

co-chairman. my name is sally satel. i'm a resident scholar at the american institute and i work at a methadone clinic in washington, d.c. and i wanted to give you an overview today of the contours of the health disparity issue. in fact, i almost call it a health disparity debate. what do i mean by debate? there are certainly no controversy over the fact that minorities have poorer health status and often poorer healthcare, both the variables that dr. chandra spoke of. there's no dispute there. but the debate has to do with the causes of those differentials and the causes, of course, lead us to the remedies. so there are two starkly different perspectives on the causes, and dr. chandra spoke to them already. he characterized them in short

as dynamics within the clinical encounter, biased physicians and even biased health systems. that's one perspective. versus the -- what i call a more socioeconomic focus. on inadequacies of health systems that disproportionately served low-incomed individuals who are disproportionately minority. the bias perspective came to the forefront of the health disparities conversation with the 2002 institute of medicine report and i want to spend a little bit of time on that. that report is called unequaled treatment. it got an enormous amount of attention and is largely regarded as a authoritative study. however, i wanted to outline some of the methodological problems with it. that study had an emphasis on the clinical encounter and concluded that there was bias among physicians towards

minority patients. overtly as well as subtly. and i think that report really was almost a watershed point in the -- in the dynamic of this debate because it really catapulted from a health issue to a civil rights one as i said with the different kind of remedies applied of sensitivity training for doctors and affirmative action and title 6 challenges. the main problem with the institute of medicine report is that it sought to prove bias or discrimination. and i just -- i speak from the standpoint solely of methodology. this is an almost impossible phenomenon to prove using retrospective approaches and using large databases, it in a sense charging a bias is a

diagnosis of exclusion. it's the kind of thing you arrive at which is not to say it doesn't exist. it could well but it's the kind of thing one arrives at after ruling out variables that we can measure and identify. the other kinds of variables that could lead to differences and with large databases, this is very hard. just one problem with the report. i've chronicled most of them in this health disparities myth booklet that i'll hand out to you afterwards. but one of the problems is that of omitted variables and you referred to this as well. when you look at large databases in retrospect you're not often going to find the kinds of variables upon which physicians make their clinical decisions. for example, if we're going to use an angioplasty, we'd want to know certain ekg subtleties that are not in large retrospective databases. obinjection fraction, for example, and projection of an occlusion of an artery. these things don't come across in these databases but they are

very relevant to clinical decisions. another feature of the report and much work in health disparities is procedure counting. how many procedures did one group get versus another? as opposed to looking at in greater emphasis in the outcome. the research in cardiac procedures has frequently shown that even though there are differentials, the mortality rates are frequently the same. so ideally, what one wants to use is prospective studies and even more ideally ethnographic innovation and with the physicians why they make the treatment decisions they do and i'm not really familiar with those kinds of studies. the iom report has set the tone for this debate. now actually i think somewhat less talk about biased physicians today and i see this as a maturing of the issue and

there's one key concept that i want to emphasize which is again in the health disparities issue an almost exclusive focus on relative health. almost a greater concern with the health of groups in relation to each other than whether people are receiving optimal care. and the reason why this is one of the problems of this approach to look at relative health is that you can often miss improvements when all boats rise so to speak. you will see no change in a ratio of minority and white improvement but it could be there. you just won't see it because everyone has improved together. another example of that has to do with the classic example is infant deaths which between the years 1980 and 2000, decreased by over one-third. now, that is certainly progress but white infant deaths increased even greater. so it still looks as if the

ratio does not -- is unfavorable to black infant mortality but that's not really what the whole picture shows. so one can be misled by focusing on relative health and on gaps. and one also can get conversely a false sense of achievement. 2005, harvard study found greater improvement for blacks in basic interventions and eye exams for diabetes and other things, however, the rates for blacks and whites were suboptimal for both so that wasn't necessarily something to celebrate either. now, as far as the most relevant determi determinance you've heard of them from the doctors. geographical of hospitals, the quality, the idea of minorities and whites don't really even see the same physicians. these are drivers of health differentials are very powerful and in my view swamp the value for looking for bias assuming

that bias could even be satisfactorily be demonstrated. now, perhaps even more profound of the healthcare of the determinants of my colleagues. the mechanisms are complex, these are called the upstream factors of education and parental income and neighborhood. the mechanisms are complex but scholars generally agree that good structured education in the early years enables children to develop self-control, problem-solving, dispossessions and not least a sense of the future. what does this mean for health in later life, well, obviously it means more opportunities to obtain decent jobs, jobs with health benefits, more autonomy. that was one of the key lessons of the classic whitehall civil servant study which looked at the gradiants of income and found the second to the highest gradient still had disproportionately higher cardiac mortality than one would

expect even though their incomes were very good. but the conclusion was that they did not have the latitude to determine -- to determine how they worked in the job. there was a sense of stress, of responsibility without authority. so stress is quite important. also good education gives you the financial security to cushion setbacks. people are better informed, of course, about health matters and have a much positive view of technological interventions. now, let me move from the more abstract to what i see when i go to my clinic here. it's a methadone clinic so by definition we're treating people who have heroin addiction but they've got a lot of other medical problems. what i had said the foregoing was to call attention to the factors that really do matter. these are factors that vary by race, not necessarily because of race. but in the weeds, in the clinic,

we see folks that -- i think everyone is really talking about when we speak of the medical disenfranchi disenfranchised. it would help these folks especially black men who really have medicaid unless they are disabled but even so there's much more to better health and access. this has been mentioned before. a continuity of care, the same doctor is so important. a medical home, ample time. the commonwealth funded a wonderful poll in the late '90s. over 1,000 people have -- about eight different ethnic groups and asked them so many questions about how they determined which practitioner they want to go to. and out of 13 options, race came in tied last with something else. many patients should have -- people should have the option to choose their physician based on race but the patients in this survey and as i said there were over 1,000, they said that was really the least relevant. the doctor spending time with them was one of the most so that

is so -- that is very important. access again as i said is huge but the determinants have to do often with engagement. will patients engage in the self-care that you mentioned. that is so important because so many have chronic illnesses which contribute tremendously to the healthcare burden. and so i personally for this kind of problem and for my kinds of patients actually i'm a great fan of local public health clinics. this is very much, you know, on the ground. we're talking 5 feet above. not the 100,000-foot view but where you can have hours we're open nights for the working poor a location that's convenient, keep people out of the emergency rooms, staffed with local residents. i think that goes very far to the cultural sensibilities that we're all talking about.

these physician assistants and nurses, they help the physicians. they do the support. they do the outreach. they make that follow-up calls. so in summary, time for my summary? >> yes. [laughter] >> three points very quickly recognize that the elimination of health differentials is not feasible because we cannot eliminate the disparities, the social disparities, many of which take their most profound toll in terms of the habits of mind and view of the future into adulthood. that affects health, such an agenda clearly transcends the work of public health and is best left to politicians, voters and the social welfare experts. i'll stop there. thank you. >> thank you. doctor? >> thank you very much. for this invitation. i'm really thrilled that you're having this hearing and i want to say metaphorically and the fact that i'm jammed at the end of the table i find to be a great turn of events of the