February 18, 2020

Editor's note: A previous version of this story incorrectly identified Austin Frakt as a physician. It has been updated to show he's an associate professor at Boston University’s School of Public Health.

"Put simply, people of color receive less care—and often worse care—than white Americans," Austin Frakt, an associate professor at Boston University's School of Public Health, writes for the New York Times' "The Upshot," drawing attention to a history of patient consent violations that has fueled black patients' distrust in the system.

Slide deck: Health Equity 101

What the evidence shows about racial gaps in health outcomes

Studies show that black patients receive worse quality care for conditions such as cancer and HIV as well as worse quality preventive and prenatal care, Frakt notes. Black patients are also less likely to receive any treatment for cardiovascular disease but are more likely to have a limb amputated unnecessarily.

And because care is worse for people of color, "their health outcomes are worse," Frakt writes. He notes that black men experience the worst health outcomes of any other demographic group, and at age 45, black men have a life expectancy that is three years less than non-Hispanic white men.

How patient consent violations changed the course of health care for black men

A study published in the Quarterly Journal of Economics attributes black men's poor health outcomes and reduced life expectancy in part to the U.S. Public Health Service's 40-year Tuskegee Experiment, a violation of trust that "shook African-Americans' confidence in the nation's health system," Frakt writes.

For the experiment, the Public Health Service from 1932 to 1972 followed about 600 low-income black men in Tuskegee, Alabama, 400 of whom had syphilis. The Public Health Service's actual intention behind the study was to observe the natural progression of syphilis, but in order to get black men to participate, the agency lied to participants about the study's purpose and told them they would receive treatment for their condition.

Throughout the study, the Public Health Service gave the patients fake treatments, even after Penicillin was being used to successfully treat the disease in the late 1940s, according to CDC. As a result, the disease progressed in the patients, many of whom "needlessly passed the disease on to family members, suffered, and died," Frakt writes.

In the end, the Tuskegee study "revealed more about the pathology of racism than it did about the pathology of syphilis," according to Allan Brandt, a historian and professor of medicine at Harvard University. Frakt also argues that the study was unnecessary, noting that at the time of the study, "the natural course of syphilis was already largely understood."

Today, the study is considered to be a main driver behind black patients' distrust of the U.S. health care system, Frakt writes. "That distrust has helped compromise many public health efforts—including those to slow the spread of HIV, contain tuberculosis outbreaks, and broaden provision of preventive care," Frakt writes.

One analysis, Frakt writes, "suggests that one-third of the black-white gap in male life expectancy in the immediate aftermath of the study could be attributed to the legacy of distrust connected to the Tuskegee study." He notes that while the study used observational data, leaving "room for skepticism about the specific findings and interpretation," they're still "consistent with lots of other work that reveals African-Americans' distrust of the health system, their receipt of less care, and their worse health outcomes."

Why black men have better health outcomes with black doctors

Frakt also points to a recent study that further highlights the role of race in health outcomes. The study randomly assigned 1,300 black male patients to one of 14 black or nonblack male primary care physicians and found that black men received better care when they saw black male physicians. The patients who saw black doctors received 34% more preventive services than the patients who saw nonblack doctors. "One reason for this," the study found "is increased trust and communication," Frakt writes.

According to the researchers, if all black men received a 34% increase in preventive services as well as proper follow-up care, it could reduce the difference in mortality rates between black and white men by 8%.

But the reality is that black men couldn't all see black doctors "even if they wished to," Frakt writes. That's because blacks make up only 4% of physicians and less than 7% of medical school graduates.

So while the Civil Rights Act prohibits race or color from being used to deny the "benefits of, or be subjected to discrimination under any program or activity receiving federal financial assistance," the fact that "nearly every facet of the American health system receives federal financing and support, well-documented and present-day discrimination in health care suggests the law has not yet had its intended effect," Frakt concludes (Frakt, "The Upshot," New York Times, 1/13; CDC.gov, accessed 1/17).

Health Equity 101

Health care delivery is incomplete without addressing the social determinants of health that contribute to health disparities. However, providers often find it difficult to pinpoint the areas of health inequity that need the most attention in their communities.

Download the slide deck from our recent webinar to learn how to focus your identification efforts on a community and patient level to inform strategic priorities and improve outcomes of at-risk patients.

Download Now
Download Now

Topics