Pharmacist Perspectives: Health Disparities Impacting Communities of Color

Heart disease. Cancer. Infant and maternal mortality. COVID-19. When we think of those things, we know how devastating they can be to people across people from all walks of life in the United States.

Heart disease has been the leading cause of death in the US for over 80 years, and cancer is slowly trending towards surpassing it. Infant mortality (death) is alarmingly prevalent in the US – the US ranks 33^rd of 36^th amongst developed nations in infant deaths per 1,000 live births, according to the United Health Foundation’s “America’s Health Rankings”. And, of course, we all know the impacts that the COVID-19 pandemic has had everywhere, including on even our own loved ones.

However, what may not be immediately clear to some is the striking statistical differences in health outcomes that exist amongst Black, indigenous, and people of color (BIPOC) living in this country.

As highlighted in Table 1, there are stark contrasts in death associated with major health conditions when comparing BIPOC to white Americans. For example, Black women are over 3 times more likely to die of pregnancy-related complications than white women, and the infant mortality rate is nearly double. As a whole, these numbers have trended down over the years alongside the progression of modern medicine. But, the rate at which they have decreased is much slower than that of white Americans.

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Table 1: Mortality Rates of Common Causes of Death in Different Racial/Ethnic Groups

	Heart disease	Cancer	Infant & Maternal Mortality
Black	208 per 100,000 people	169 per 100,000 people	Infant: 10.8 per 1,000 live births Maternal: 41 per 100,000 live births
Hispanic	114 per 100,000 people	108 per 100,000 people	Infant: 4.9 per 1,000 live births Maternal: 12 per 100,000 live births
White	169 per 100,000 people	150 per 100,000 people	Infant: 4.6 per 1,000 live births Maternal: 13 per 100,000 live births

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The story goes much further than just mortality rates – risk factors for a myriad of health conditions show the same trend.

For example, Black adults over the age of 20 years are 21% more likely than white adults to have high blood pressure. Hispanic adults are about 9% more likely to develop diabetes and obesity than white adults. BIPOC may be more likely to live in areas with increased exposure to harmful environmental chemicals such as radon, which has been linked to lung cancer. These comorbidities (multiple health conditions) contribute significantly to the risk of pregnancy-related complications, which may be a direct reason for higher maternal and infant mortality amongst Black women.

It is evident through available data that BIPOC are disproportionately affected when it comes to treatable health conditions. Mental health conditions, inflammatory bowel disease, end-stage renal (kidney) & liver disease, strokes, hepatitis B are all examples of more disease states that show higher incidence and/or mortality among BIPOC compared to white Americans.

So, this begs the question: why do we see such shocking disparities in health for BIPOC? To even begin to answer that question, we must first understand history. Medical mistreatment – and the long-term consequences of it – against communities of color, namely Black Americans, has endured over several generations. This is critical in understanding the health disparities we see today.

A Long History of Mistreatment

After a young Black woman named Henrietta Lacks gave birth to her son Joseph at Johns Hopkins Medical Center in 1951, she had a severe hemorrhage (internal bleed). This resulted in a cervical biopsy, amongst other tests, being performed to help determine an underlying cause. A few days later, the results returned with devastating news – cervical cancer. She was treated with radium and told to follow up several days later. During these treatments, samples of cells were taken from her cervix to be studied by cancer researchers. However, no hospital staff asked Henrietta for her permission to collect these cells and experiment with them. Nobody even informed her that her cells were taken at all, and 6 months later she died at the age of 31 years.

These tissue samples eventually led to the discovery of the very first immortalized human cell line (called HeLa cells). They have turned out to be one of the most important cell lines in medical history, reproducing infinitely when placed under certain conditions. Cancer, AIDS, gene mapping, and countless other scientific endeavors have been researched and discovered using HeLa cells.

Although it was not yet common practice or law at the time to obtain informed consent from a patient when collecting tissue samples for research, the story of Henrietta Lacks still serves a crucial purpose. It demonstrated the medical mistreatment of Black Americans, as Ms. Lacks or her family were never told that she had tissue samples taken – or that they led to an incredibly important scientific discovery – until nearly 20 years after she had passed.

Around the same time as Henrietta Lacks, arguably the most infamous biomedical research study in US history – the Tuskegee Syphilis Study – was conducted in Tuskegee, Alabama. It ran from 1932 to 1972 and its purpose was to observe the natural history and progression of untreated syphilis. It was proposed to the 600 enrollees – who were all impoverished Black sharecroppers – as an opportunity to receive free medical care from the federal government. The study was run by the US Public Health Service, the CDC, and The Tuskegee Institute.

Of the men in the study, 399 of the 600 had latent syphilis – however, these men were never actually informed of their diagnosis. Patients were given “treatment” that consisted of placebos such as aspirin or mineral supplements. Additionally, unnecessary and dangerous diagnostic procedures were performed, such as spinal taps, and they were disguised as cures. In addition, the men were told that the study would last 6 months, but it ended up lasting 40 years.  About halfway through the study, penicillin was developed. It became standard of care for syphilis by 1947; however, investigators not only neglected to treat participants with this potentially life-saving drug, but also prevented them from going to other legitimate penicillin treatment centers in the area.

As a result of never receiving treatment, 128 of the men in the study died. As for those who survived, they all suffered through severe complications of the disease. Blindness, brain damage, mental illness, heart disease, and bone deterioration were just some of the effects seen. Additionally, 40 of the men’s spouses contracted the disease and 19 of their children were born with congenital syphilis, a type of syphilis passed from a mother to a baby while in the womb.

In 1972, the details of the study were revealed to the public and it was quickly shut down. The following year, Congress reached settlements with the study’s surviving participants and families. New federal guidelines were created to protect human research subjects. However,, the damage to the trust of Black Americans in the US healthcare system had already been done.

It lingers to this very day.

The stories of Henrietta Lacks and the Tuskegee Experiment serve to illustrate the longstanding medical mistreatment of Black Americans in the US and the resulting distrust and hesitancy to receive care that we still see today. As we seek to understand and address health disparities within communities of color, it is increasingly important to recognize the history that helped to create them.

Health Disparities in the Age of COVID-19

As we now enter year 2 of the global pandemic COVID-19, over 500,000 American lives have been lost. We have seen the damage this disease can do on people, their families, and their livelihoods. And just as we have seen with health conditions such as heart disease and cancer, there are also stark differences in mortality of COVID-19 in communities of color, particularly Black and Hispanic Americans.

2.8 times is the rate at which Black and Hispanic Americans are dying from COVID-19 compared to white Americans. This is an alarming number, and it has drawn a lot of attention in both the medical community and society at large. We have already explored some more general health disparities as well as the history that perpetuated them. However, it is important to circle back to the current global health crisis at hand and analyze the uniquely devastating challenges that it has brought to BIPOC.

Although this is not meant to oversimplify a very complex issue, the reasons for higher COVID-19 mortality in BIPOC can be broken down into 3 main reasons:

1) More comorbidities/risk factors

• Conditions such as cancer, heart disease, diabetes, and obesity lead to a higher chance for severe illness
• Less likely to live in areas with healthy food, gyms, and green spaces
• More likely to live in “medical deserts” which leads to a lack of preventative care and increases reliance on emergency departments for primary care
• Higher rates of pollutants & toxins in water (ex: lead blood levels in Black children living in Baltimore are 30% higher than white children) which can contribute to poor health

2) Increased exposure to the virus

• More likely to live in densely populated cities or live with extended family members at home
• Black Americans represent 25% of public transit users
• Approximately 1/3^rd of bus drivers, food service workers, janitors, cashiers, and stockers (“essential employees”) are Black or Hispanic/Latino

3) Barriers to care lead to poor overall relationship between patient and provider

• Black patients often report unfair assumptions made about them (ex: Black patients are 22% less likely to receive adequate pain medications than white patients for the same diagnoses) which perpetuates medical mistreatment and mistrust
• Lack of education or awareness of language barriers (ex: 6 of 10 Spanish-speaking patients report having difficulty communicating important information with a healthcare provider)
• Implicit bias in medicine (most healthcare providers have implicitly positive attitudes towards white patients and negative attitude towards people of color) and lack of adequate training to overcome it

We know the COVID-19 pandemic has ravaged communities across the US and beyond. However, it is critically important to recognize the unique and difficult challenges that communities of color face with this pandemic and how we can move forward as a healthcare system to address them.

A Pharmacist’s Role

An article recently published in the American Medical Association’s Journal of Ethics highlighted the ways in which pharmacists and physicians can collaborate to help ensure health equity in underserved groups such as BIPOC. The article concludes by affirming that pharmacists’ skills in chronic disease state management/prevention, medication management, health and wellness, and patient advocacy should be capitalized on and utilized in a multidisciplinary approach to combat health inequity and disparities.

This is one of many examples of pharmacists taking initiative in the world of health equity, particularly for BIPOC.  Large professional pharmacy organizations such as ASHP and APhA have taken stances on combatting systemic racism, discrimination, implicit bias, and health disparities. This aligns with state and federal government goals, as well as a majority of health systems initiatives.

In all, pharmacists have not only an opportunity to better serve their patients of color, but a duty. It is written in the very oath that pharmacists take upon graduation: “I will consider the welfare of humanity and relief of suffering my primary concerns”.

As more awareness and education spreads on health disparities in communities of color, pharmacists can actively help by engaging in important discussions with peers & learners, supporting initiatives at their institutions in the field of Diversity, Equity, and Inclusion, and working to recognize and combat their own implicit biases. That is what our patients and communities deserve, and pharmacists are up to the task.

Resources to Utilize and Share

ASHP Task Force on Racial Diversity, Equity, and Inclusion

CDC Office of Minority Health & Equity

American Medical Association COVID-19 Health Equity Resources

Robert Wood Johnson Foundation Health Equity Resources  

CDC COVID-19 Racial and Ethnic Health Disparities

American Public Health Association Health Equity Guide

References:

1. United Health Foundation. America’s Health Rankings. 2018 Annual Report. Accessed 2/12/21.
2. Centers for Disease Control and Prevention. CDC Health Disparities & Inequalities Report (CHDIR). Published 2013. Accessed 2/15/21.
3. Centers for American Progress. Health Disparities by Race and Ethnicity. Published 5/7/20. Accessed 2/13/21 at https://www.americanprogress.org/issues/race/reports/2020/05/07/484742/health-disparities-race-ethnicity/.
4. Frakt A. The New York Times. Bad Medicine: The Harm That Comes From Racism. Updated 7/8/20. Accessed 2/12/21 at https://www.nytimes.com/2020/01/13/upshot/bad-medicine-the-harm-that-comes-from-racism.html.
5. Nuriddin A, Mooney G, White AIR. Reckoning with histories of medical racism and violence in the USA. Lancet. 03 Oct 2020;396(10256):949-951. doi: 10.1016/S0140-6736(20)32032-8.
6. National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Population Health and Public Health Practice; Committee on Community-Based Solutions to Promote Health Equity in the United States; Baciu A, Negussie Y, Geller A, et al., editors. Communities in Action: Pathways to Health Equity. Washington (DC): National Academies Press (US); 2017 Jan 11. 2, The State of Health Disparities in the United States. 
7. Ray R. The Brookings Institution. Why are Blacks dying at higher rates from COVID-19? Published 4/9/20. Accessed 2/16/21 at https://www.brookings.edu/blog/fixgov/2020/04/09/why-are-blacks-dying-at-higher-rates-from-covid-19/.
8. Interaction Institute for Social Change, 2016. Equality vs equity. [image] Available at: <https://www.flickr.com/photos/communityeyehealth/27755848262> [Accessed 24 February 2021].