Kidney disease is a common malady across populations. There are many causes of this disease and there seems to be a socio-economic component. In the US kidney disease tends to have a less favorable outcome among those of a lower income. This population tends to be made up of racial and ethnic minorities who are disproportionately represented in this US population with kidney disease.
A common problem when trying to address the issue of the prevalence of disease among economically disenfranchised elements of the US population, that is if the problem is determined by socio-economic status or is it the result of racism as well as racism that has been institutionalized. This problem is especially difficult to decide when one considers the history of racism and its impact on present day institutionalized racism.
Finding a link between racism and kidney disease is necessary to address the problem. While socio-economic status may seem to be the prime mover behind the disparity between better outcomes for those that are economically better off than those at the bottom of the economic scale, the determinacy of racism must be ascertained in order to address the problem of kidney disease successfully.
Ordinarily one might wonder if higher rates of kidney disease are the result of racism or the result of socio-economic factors caused by racism which results in less favorable outcomes. In order to address the problem of kidney disease in racial and ethnic minorities this issue must be resolved. Is the solution to address socio-economic conditions, institutionalized racism or face to face discrimination?
If it were socioeconomic factors that determine kidney disease then these determinants would have to be addressed. To address this problem more money would need to be put into health care and a program of preventive care would need to be instituted. Access to health care would need to be improved by those lower on the economic ladder so that health outcomes could be improved. Oftentimes though if programs are in place that provide access to services and these services do not improve health outcomes then there is the impulse to blame the victim.
But perhaps further evidence of racism among those of lower socio-economic status and a lower education level is shown by the fact that even with equitable insurance coverage and access as well as similar health insurance within the same system of care in the same managed care plan, the result is still for poorer outcomes among minorities (Bierman, 2002). Yet there are other factors that can lead to a less successful outcome in those of minorities. Those of lower socio-economic class find themselves more subject to arrest (Brooks, 2008). Also this group is more likely to be victims of crime, more likely to have housing problems, and to be families with single mothers more likely to have child care issues. All these factors can result in less adherence to a treatment regimen and must be controlled in any study.
More likely though is the other alternative. Most probably racism is the cause because minorities are the victims of a history of racism and face institutionalized racism as well as personal racism. Racism being largely unconscious and entitlement that is assumed by those higher on the economic ladder, especially whites, can make the health care provider blind to the causes of the poorer health outcomes of racial and ethnic minorities when basing their opinion strictly on socio-economic factors especially in the case of kidney disease.
It is clear that those of lower social and economic stature have a higher rate of kidney disease and are at a greater risk of death. Illegal drug use in the inner city causes higher rates of hypertension, acute and chronic kidney disease. Socio-economic factors are determinants of a higher rate of asthma, diabetes mellitus, hypertension, tuberculosis and chronic kidney disease. Cocaine use is thought to be a cause of the progression of kidney disease.
There is a greater likelihood of increased mortality and lower placement on kidney transplant waiting lists. Strictly socio-economic factors are often looked at when health insurance limits the ability of patients to pay for drugs used for the maintenance of immunosuppression in transplant patients which is limited to three years. (Nzerue, 2002)
The claim is made that racial bias is difficult to determine in surveys of physicians and other health care providers by looking at physician behavior or medical records although subtle biases are suspected which may influence physician’s therapeutic decisions. There are documented difficulties in communication between those of a lower socio-economic class and physicians who harbor negative personal perceptions of the less affluent and lower educated (Nzerue, 2002).
There are documented instances of a disproportionate less favorable outcomes among those of lower socio-economic classes among African Americans and Mexican American communities of microalbuminuria and macroalbuminuria (Tareen, 2005). But it is difficult to determine the exact factors that result in this outcome.
“Education directed toward patients and physicians is important for overcoming the many cultural differences in health beliefs and behaviors that contribute to both the risk and progression of Chronic Kidney Disease (CKD)… Adherence to referral and treatment for CKD may be improved when patients feel they receive health recommendations in a respectful and culturally considerate manner. Increasing the number of minority physicians practicing within their own communities may further help to reduce some cultural barriers” (Norris, 2005).
One study makes a strong claim of racial and ethnic disparity in low socio-economic groups. Referral and initiation of dialysis, adequacy of dialysis and anemia management-with non-white patients are usually at a disadvantage. For example Whites and Asian Americans are more likely to be placed on peritoneal dialysis compared with African American and Native Americans. “Factors in treatment for kidney disease are not completely explained through socio-economic determinants. Factors such as cultural bias, … physician bias and communication barriers all contribute to lower peritoneal dialysis among certain minority groups” (Gadegbeku, 2002).
Another issue that comes out in this study is that there is what is termed “Transplantation Reluctance.” It seems clear that while there are socio-economic factors that lead to a higher incidence of kidney disease and less favorable outcomes, it seems clear that racially specific differences can be eliminated [and identified] when a multi-faceted approach is adopted (Gadegbeku, 2002).
Much remains to be done to eliminate socio-economic, racial and ethnic biases that permeate the health care establishment. By separating the socio-economic factors from the racial factors one can institute strategies which address these shortcomings that are the direct result of racism.
Only through determining the racial and ethical component in this equation can disparities that deprive African Americans, Latino American and Native Americans access to affordable, effective and fair health care provision. Only in order for society to be just and enabling minorities to be effectively brought into the health care establishment will discrepancies between minorities and whites be addressed.
References:
Bierman, A.S., Lurie, N., Collins, K.S., & Eisenberg, J.M. (2002). Addressing racial and ethnic barriers to effective health care: The need for better data. Health Affairs, 21(3), 91.
Brooks, D., Charleston, J., Dowie, D., Gabriel, A. I., Hall, Y. B., Hiremath, L., Lightfoot, T., Sika, M., Smith, W. C., Wang, X. (2008). Predictors of Participant Adherence and Retention in the African American Study Of Kidney Disease and Hypertension. Nephrology Nursing Journal, 35(2), 133-42. Retrieved July 16, 2008, from ProQuest Medical Library database. (Document ID: 1470818171). http://proquest.umi.com/pqdweb?did=1470818171&sid=2&Fmt=3&clientId=29440&RQT=309&VName=PQD
Gadegbeku, C., Freeman, M., Agodoa, L. (2002). Racial disparities in renal replacement therapy. Journal of the National Medical Association: Racial Disparities in Kidney Disease, 94(8), 45S-54S. Retrieved July 16, 2008, from ProQuest Medical Library database. (Document ID: 160201271). http://proquest.umi.com/pqdweb?did=160201271&sid=2&Fmt=4&clientId=29440&RQT=309&VName=PQD
Norris, K. C., et al., (2005). Unraveling the racial disparities associated with kidney disease1. Kidney International, 68(3), 914-24. Retrieved July 16, 2008, from ProQuest Medical Library database. (Document ID: 1014509361). http://proquest.umi.com/pqdweb?did=1014509361&sid=2&Fmt=6&clientId=29440&RQT=309&VName=PQD
Nzerue, C.M., Demissachew, H., & Tucker, J.K. (2002). Race and kidney disease: Role of social and environmental factors. Journal of the National Medical Association, 94(8), S28-S39.
Tareen, N., Zadshir, A., Martins, D., Pan, D., Nicholas, S., & Norris, K. (2005). Chronic kidney disease in African American and Mexican American populations. Kidney International, 68(S97), S137-S140.
Health cannot and should not be focused on some while ignoring others. Living in a country that plays lip service to equal rights for all often neglects the material needs to many. Nowadays with services being cut and wealth being appropriated by the upper classes health care for the poor has suffered greatly. Because of the history of racial discrimination the distribution of poverty weighs heavily on certain ethnic groups especially Blacks, Latinos, and Native Americans. It is clear that racism has been used as an excuse and has become institutionalized to justify consciously or not the inequitable distribution of wealth.
To disregard the health of some is unjust in a society and it is clear that the role of those who care about the health of others is that the greatest efforts must be taken to address the health of all no matter what obstacles stand in the way. This tradition is in fact an essential part of a mission of public health. Justice is viewed as so central to the mission of public health that it has been described as the field’s core value (Gostin, 2006).
Contributing Factors in Health Disparity
Traditional US society revolves around white male privilege. All social structure reflects European values. The white settlers eliminated any threat to their rule. The native people were largely exterminated, and the African were kidnapped and forced to work as slaves. It’s ironic that in the land of the free so many people have been denied their rights. Racism was intentionally integrated into the social structure and has subsequently become institutionalized.
The impact of racial discrimination is profound and in order for there to be improvement in health outcomes racism must be addressed. Strategies for measuring the depth of discrimination are readily available. For example for any one objective, progress toward the elimination of racial and ethnic disparities is measured in terms of changes in the relative difference between the best group rate and the rate for each of the other racial and ethnic groups…Disparities can also be viewed in terms of burden – that is, the number of people with limitations, risk factors, adverse health conditions, or health care access problems (Keppel, 2007).
Some make the claim that if one wants to they can pull themselves up by their bootstraps but when lacking even the most basic services this is most certainly impossible. Living in an impoverished neighborhood decreases ones survival odds. Inner city pollution and lack of fresh food as well as crime decrease survival odds. The negative impacts of these variables on individual people can be considered as the impact of one lacking in social capital. Nevertheless strategies to address a deficit of social capital are not sufficient as other unrecognized factors may exist.
The things many take for granted are not available to some in society. Intervening in communities to increase their levels of social capital may be ineffective, create resentment, and overload community resources, and to take such an approach may be to “blame the victim” at the community level while ignoring the health effects of macrolevel social and economic policies (Pearce, 2003).
In a society where wealth is not equitably distributed and where institutionalized racism exists certain minorities are going to suffer greatly. In the UK an example of the economic impacts are for instance that infant mortality rates for a social class V, that of unskilled manual workers, are twice that for a boy born into the professional and management classes, a social class I. In the USA, race and ethnicity are major factors (Anonymous, 2006).
In order to address inequitable health outcomes one must get to the root cause of these outcomes. A common opinion is that socio-economic considerations are central yet little investigation is done in the US regarding the impact of these socio-economic factors but focuses on racial inequalities almost exclusively. This is in contrast to Europe, where health statistics have routinely included socioeconomic data. The net effect has been to remove from view – and from policy discourse-the pervasive patterning of US health disparities by socioeconomic position within and across racial/ethnic groups, as well as to retard understanding of the contribution of racial discrimination to US racial/ethnic health disparities (Krieger, 2005).
Another error that commonly occurs since the criteria for analysis of health outcomes depends on ethnic factors only, often to address this inadequacy categories of racial identifiers are used inexactly to model socio-economic factors that result in unequal health outcomes. The easy availability of “racial” identifiers in public health databases has led researchers to sometimes use “race” as a crude proxy for economic inequality (Williams, 1997).
It is clear that socioeconomic factors are not the only reason that minorities suffer greatly in the USA. New immigrants not familiar with the language, customs and religion may suffer a well. Language is always a big barrier and this is particularly true for older newly arrived immigrants. Practitioners not familiar with the ancestral cultures of new immigrants may not be able to provide the services they need.
For example Mexican families are extended families and decisions are made by the group and not by any individual such as the patient themselves. Also the male patriarch in the clan must be consulted in any matter that must be decided. In non-native speakers it is important to have an independent interpreter rather than having the patient’s children or grandchildren doing the interpreting. One reason for this is that those translating may hide the severity of the issue at hand to protect the feelings of the patient. Also if a child is involved then this will give them a position of authority something that may be resented by the clans extended family. These and other oversights may have unforeseen consequences for care.
Achieving Positive Health Outcomes
There must be sensitivity to racist behavior in society and institutional racism. Steps must be taken to address racism in society and ensure that an economic distribution of wealth exists to adequately fund excellent health care for all. It is not enough to see that different ethic groups are treated the same. This will only result in poverty being equally distributed among ethnic groups. Rather efforts must be made to recognize those things that hold people down and rob them of their social capital, and we must empower the poor of all ethnic groups and involve them in their own care.
A thorough self examination must be instituted by the practitioner to understand ones own biases so that one can understand how these biases effect interaction with others, especially other ethnic groups. Also an effort must be made to be sure health care facilities in all areas are able to provide support services to any population regardless of the economic stature of the supported area. Only with this infrastructure can all segments of a population be served. Only when these resources are available including preventive care, acute and chronic care, including healthy lifestyle classes can people’s health outcomes be improved.
Observations For Health Science Research
The US medical system has fallen into disarray. There is no doubt the health care in the USA is unparalleled in sophistication and the superiority of treatment. The problem lies in the fact that so many are not insured and therefore lack access to health care. The poor who have no insurance have largely been thrown to the wind. Without preventative care death rates are much higher. With preventative care much chronic disease can be prevented. Avoiding poverty can enable people to eat healthier diets rather than being dependent on the local burger stand.
In 1988, the Director General of the WHO was already concerned that, “public health has lost its original link to social justice, social change and social reform” (Hancock, 1999). Twenty years later, the lack of accountability by public health practitioners remains the same. Health promotion must recover its original role and challenge social inequalities in health (Ridde, 2007).
The object of this endeavor is not to evoke an ideology of a redistribution of wealth but that this endeavor is really is a question of science. The task will be to demonstrate an evidence-based way to reduce socioeconomic disparities and to show that this improves health outcomes (Gostin, 2004). The evidence of racial and ethnic disparities in health outcomes is overwhelming. Excess deaths and excess morbidity and disability are clearly prevalent among racial and ethnic minority elders (Johnson, 2002).
The average health status of members within every society on earth increases in a stepwise fashion as one ascends from the bottom of the social ladder (defined, variously, by income, education or occupation) to the top (Hertzman, 2001). Ultimately to address this problem justly commensurate health services must be made available to all.
References:
Anonymous, Measuring progress on health disparities. (2006). The Lancet, 367(9526), 1876. Retrieved May 12, 2008, from ProQuest Medical Library database. (Document ID: 1060415791). http://proquest.umi.com/pqdweb?did=1060415791&sid=8&Fmt=4&clientId=29440&RQT=309&VName=PQD
Gostin, Lawrence O et al. (2004). The Future Of The Public’s Health: Vision, Values, And Strategies. Health Affairs, 23(4), 96-107. Retrieved May 12, 2008, from ABI/INFORM Global database. (Document ID: 661524771). http://proquest.umi.com/pqdweb?did=661524771&sid=8&Fmt=3&clientId=29440&RQT=309&VName=PQD
Gostin, Lawrence O et al. (2006). What Does Social Justice Require For The Public’s Health? Public Health Ethics And Policy Imperatives. Health Affairs, 25(4), 1053-1060. Retrieved May 12, 2008, from ABI/INFORM Global database. (Document ID: 1083916871). http://proquest.umi.com/pqdweb?did=1083916871&sid=8&Fmt=3&clientId=29440&RQT=309&VName=PQD
Hertzman, Clyde (2001). Health and human society. American Scientist, 89(6), 538-545. Retrieved May 12, 2008, from Research Library database. (Document ID: 87509292). http://proquest.umi.com/pqdweb?did=87509292&sid=8&Fmt=3&clientId=29440&RQT=309&VName=PQD
Johnson, Jerry C. et al (2002). Health and social issues associated with racial, ethnic, and cultural disparities. Generations, 26(3), 25-32. Retrieved May 12, 2008, from Research Library database. (Document ID: 275408581). http://proquest.umi.com/pqdweb?did=275408581&sid=8&Fmt=4&clientId=29440&RQT=309&VName=PQD
Keppel, Kenneth et al. (2007). Improving Population Health And Reducing Health Care Disparities. Health Affairs, 26(5), 1281-92. Retrieved May 11, 2008, from ABI/INFORM Global database. (Document ID: 1339614071). http://proquest.umi.com/pqdweb?did=1339614071&sid=5&Fmt=4&clientId=29440&RQT=309&VName=PQD
Krieger, Nancy et al. (2005). Painting a Truer Picture of US Socioeconomic and Racial/Ethnic Health Inequalities: The Public Health Disparities Geocoding Project. American Journal of Public Health, 95(2), 312-23. Retrieved May 12, 2008, from ABI/INFORM Global database. (Document ID: 820516561). http://proquest.umi.com/pqdweb?did=820516561&sid=8&Fmt=6&clientId=29440&RQT=309&VName=PQD
Pearce, Neil et al. (2003). Is social capital the key to inequalities in health? American Journal of Public Health, 93(1), 122-9. Retrieved May 12, 2008, from ABI/INFORM Global database. (Document ID: 277203851). http://proquest.umi.com/pqdweb?did=277203851&sid=8&Fmt=4&clientId=29440&RQT=309&VName=PQD
Ridde, Valéry (2007). Reducing social inequalities in health: public health, community health or health promotion? Promotion & Education, 14(2), 63-7, 111-4. Retrieved May 11, 2008, from ProQuest Medical Library database. (Document ID: 1302586891). http://proquest.umi.com/pqdweb?did=1302586891&sid=5&Fmt=3&clientId=29440&RQT=309&VName=PQD
Williams, David R (1997). Missed opportunities in monitoring socioeconomic status. Public Health Reports, 112(6), 492-4. Retrieved May 12, 2008, from ProQuest Medical Library database. (Document ID: 23988208). http://proquest.umi.com/pqdweb?did=23988208&sid=8&Fmt=3&clientId=29440&RQT=309&VName=PQD