In the spirit of Heart Month and Black History Month, which both occur in February in the United States, I was asked to take on the difficult question of equity in cardiovascular health in the African American community. But how does cardiovascular health relate to equity? To look at this, we have to look at equity in health and how it affects heart disease.
At one level, the question points to a simple answer: Surely the enhancement of the health of African Americans must be accepted more or less universally to achieve the concept of health equity. But this elementary recognition does not, on its face, take us very far, thus making the question of cardiovascular health equity more complicated. Is it good enough to have access to health care? You can be treated in the emergency room and not receive the appropriate follow-up for your chest pain because of a lack of insurance or a lack of enough insurance (underinsured). So you have access to care and can get it but will have to find your own way to pay for it. Is access enough for equity, or can we get closer to achieving it if we consider healthcare a right? We have to be able to answer these questions to understand the disparities and inequalities of healthcare for African Americans.
Unequal Access and Healthcare Inequality in the United States
Among the most important freedoms that we can have is the freedom from avoidable ill-health and from escapable mortality. It is as important to understand the qualified and contingent nature of the relationship between economic prosperity and good health as it is to recognize the crucial importance of this relationship (qualified and contingent though it may be). One may think that economic development is directly proportional to health equity and access. But healthcare and survival for particular US groups is comparable to that of people in developing nations. In the United States, African Americans have a higher mortality than people born in China, Sri Lanka, Jamaica, or Costa Rica. Despite this, African Americans arguably have a better income status than the average person in China (even after correcting for cost-of-living differences). If we consider African Americans in specific communities, we get an even sharper contrast. The African American male populations in the District of Columbia, St. Louis, New York, or San Francisco fall behind the Chinese at an even earlier age, despite the fact that African Americans in these US cities have a higher level of average income than the Chinese population they are being compared to.
While health and survival do contribute, to some extent, to the ability to earn a higher income (given other things), the truth is more multifaceted. Intercountry comparisons indicate that, by and large, income and life expectancy move together. But it would be a gross generalization to assume that economic progress is the key to enhancing health equality and longevity. The first point to note is that the enhancement of health is a constitutive part of economic development. Good health is an integral part of good economic development. Second, given other things, good health and economic prosperity tend to support each other. Healthy people can more easily earn an income, and people with a higher income can more easily seek good long-term medical care that is not dependent on emergency departments, have better nutrition, and have the freedom to lead healthier lives. Third, “other things” are not given, and the enhancement of good health can be helped by a variety of actions, including public policies (such as the provision of epidemiological services and medical care). While there seems to be a good general connection between economic progress and health achievement, the connection is weakened by policy factors.
African American Medicare Patients Experience More Cardiovascular Events
But how does this impact racial disparities in cardiovascular health? While hospital admissions decreased substantially for elderly Medicare patients in the past decade, there was less of a decrease in the African American subpopulation, according to a 2011 study of Medicare. African Americans continued to experience more acute myocardial infarctions than the general population. And when this is seen through the lens of advances in primary and secondary prevention, African Americans appear to benefit less from these medical and technological improvements than the general populace. Alternative, less likely hypotheses can also be espoused, such as cardiovascular risk factor disparities seen in hypertension, diabetes, and obesity or shifts in coding diseases in the health record.
Yet, the issue is not just about a numerical difference in diagnosis but in the treatment following diagnosis. In an epidemiologic study of variations between US African American and white patients with acute myocardial infarction, 57,342 whites (87.4%) and 8,291 African Americans (12.6%) were admitted with a primary diagnosis of acute myocardial infarction to over 1,200 US hospitals in markets with at least 50 African Americans presenting with acute myocardial infarction. Black and white patients were analyzed for differential hospital admissions. Blacks were 12% less likely to be admitted to a high-quality hospital and 13% less likely to be admitted to a hospital with coronary revascularization capability. This, despite the fact that blacks in this epidemiologic study lived closer to high-quality hospitals and hospitals with revascularization capability, thus indicating a lower propensity for admission to the closer hospital (p<0.001). Indeed, they were 17-30% more likely to be admitted to the lower-quality hospitals and teaching or safety-net hospitals. These differences may contribute to the variability in healthcare access to treatments of cardiovascular diseases. This differential admission pattern persisted even after correcting for zip code and hospital choice.
Another study found no difference in hospital admissions, but when hospital proximity was accounted for, the odds ratio increased to 1.68. In both cases, quality was defined by standard process measures and performance indicators rather than by subjective, nonstandard reporting. In both examples, racial differences in access to high-quality hospitals was driven not by race itself but by differences in where the majority of blacks and whites live and seek care, suggesting that effective public policy aimed at reducing disparities could make an impact on this cardiovascular healthcare disparity and should be taken into consideration. A similar phenomenon can be seen in stroke.
Finally, even when an economy is poor, major health improvements can be achieved through using the available resources in a socially productive way. It is extremely important in this context to pay attention to the economic considerations involving the relative costs of medical treatment and the delivery of healthcare. There is nothing as important as informed public discussion and the participation of the people involved in pressing for changes that can protect our lives and liberties. The public has to see itself not only as a patient but also as an agent of change. The penalty of inaction and apathy can be illness and death and continued inequity.
Public Policy Guided by Change Agents is Required to Achieve Cardiovascular Health Equality
While I could speak to improvement in cardiovascular risk factors such as hypertension, diabetes, and obesity, or conditions such as heart failure and heart disease, all areas disproportionately seen in the African American community, the improvements we have witnessed over the past 50-70 years are due not just to an improvement in income but to changes in public policy. In order to continue to move forward with reduction and even elimination of the medical and treatment gap of cardiovascular disease in African Americans, there must be continued assessment, reassessment, and improvement of public policies that affect healthcare. The data is out there and has been established for years (see Figure 1). What is needed now is for the underserved to act as their own change agents to improve their cardiovascular healthcare equity.
- Brennan Ramirez LK, Baker EA, Metzler M. Promoting health equity: A resource to help communities address social determinants of health. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; 2008.
- Easterlin R. How beneficent is the market? A look at the modern history of mortality from European Review of Economic History. Oxford University Press 1999;3(3):257-94. http://www.jstor.org/stable/41377854.
- Anand S, Ravallion Human development in poor countries: On the role of private incomes and public services. J Economic Perspectives. 1993;7(1):133–50.
- Sen A. Mortality as an indicator of economic success or failure. The Economic J. 1998;108(446): 21-5.
- Michaud CM, McKenna MT, Begg S, et al. The burden of disease and injury in the United States 1996. Population Health Metrics. 2006; 4:11-60.
- Sen A. The economics of life and death. Scientific American. May 1993: 40-47.
- Sen A. WHO Keynote Address: Health in Development. Geneva. 52nd World Health Assembly; 18 May 1999.
- Wang OJ, Wang Y, Chen J, Krumholtz HM. Recent trends in hospitalization for acute myocardial infarction. Am J Cardiol. 2012 June 1; 109(11): 1589–93.
- Ioana Popescu I, Cram P, and Vaughan-Sarrazin MS. Differences in admitting hospital characteristics for black and white medicare beneficiaries with acute myocardial infarction. Circ 2011;123:2710-6.
- Blustein J, Weitzman BC. Access to hospitals with high-technology cardiac services: how is race important? Am J Public Health. 1995;85:345–51.
- Kleindorfer DO, Khoury J, Moomaw CJ, et al. Stroke incidence is decreasing in whites but not in blacks. Stroke. 2010;41:1326-31.
- Figure 1 is adapted from Kochanek KD, Arias E, Anderson RN. How did cause of death contribute to racial differences in life expectancy in the United States in 2010?. NCHS Data Brief. No. 125, July 2013.