1. Social Factors Matter Class, Race and Gender in Health Outcomes

2. Important Points to Consider  Social class (which relates to occupation) is the most important predictor of health outcomes.  Rates of disease and death differ between regions of the world.  Racism of health professionals explains differences in health care between whites and minorities.  Sexism leads to higher rates of death among women with respect to heart disease.

4. Differences between the wealthy and poor nations in the world  Children in poorer nations have a higher risk of dying than in wealthier nations.  98% of child deaths (10.5 million) occur in the poorer nations of the world.  Life expectancy and mortality figures have gotten worse in the past ten years for Africa.

5. Infectious and parasitic diseases are the main causes of death in poorer nations  Adults tend to die of non-communicable diseases in the richer nations (9 of 10 people).  Poorer nations of Latin America, Asia and the Western Pacific see 3 out of 4 deaths from non- communicable diseases.  In Africa only 1 in 3 deaths result from non- communicable disease.  80% of the nearly 3 million deaths from AIDS occur in sub-Saharan Africa.

6. Leading causes of death in children in developing countries  1 Perinatal conditions  2 Lower respiratory infections  3 Diarrhoeal diseases  4 Malaria  5 Measles  6 Congenital anomalies  7 HIV/AIDS  8 Pertussis (whooping cough)  9 Tetanus  10 Protein-energy

7. Class and Health  People in lower classes tend to have more health problems including psychiatric disorders  Disparity in wealth and health is getting worse  Employees within the same firm will have health outcomes consistent with their rank in the firm

8.  Class Matters: Heart Attacks, and What Came Next  http://www.nytimes.com/indexes/2005 /05/15/national/class/ http://www.nytimes.com/indexes/2005 /05/15/national/class/

12. Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare Institute of Medicine

13. Access (e.g., insurance status, ability to pay for healthcare) is the most important predictor of the quality of healthcare across racial and ethnic groups Access (e.g., insurance status, ability to pay for healthcare) is the most important predictor of the quality of healthcare across racial and ethnic groups It is difficult – even artificial – to separate access-related factors from social categories such as race and ethnicity It is difficult – even artificial – to separate access-related factors from social categories such as race and ethnicity The bulk of research on healthcare disparities has focused on black- white differences – more research is needed to understand disparities among other racial and ethnic minority groups The bulk of research on healthcare disparities has focused on black- white differences – more research is needed to understand disparities among other racial and ethnic minority groups Caveats – Unequal Treatment

14. Non-Minority Minority Difference Clinical Appropriateness and Need Patient Preferences The Operation of Healthcare Systems and the Legal and Regulatory Climate Discrimination: Biases and Prejudice, Stereotyping, and Uncertainty Disparity Quality of Health Care Figure 1: Differences, Disparities, and Discrimination: Populations with Equal Access to Health Care Populations with Equal Access to Health Care

15. Evidence of Racial and Ethnic Disparities in Healthcare  Disparities consistently found across a wide range of disease areas and clinical services  Disparities are found even when clinical factors, such as stage of disease presentation, co-morbidities, age, and severity of disease are taken into account  Disparities are found across a range of clinical settings, including public and private hospitals, teaching and non- teaching hospitals, etc.  Disparities in care are associated with higher mortality among minorities (e.g., Bach et al., 1999; Peterson et al., 1997; Bennett et al., 1995)

16. What is the Evidence that Physician Biases and Stereotypes May Influence the Clinical Encounter? van Ryn and Burke (2000) - study conducted in actual clinical settings found that doctors are more likely to ascribe negative racial stereotypes to their minority patients. These stereotypes were ascribed to patients even when differences in minority and non-minority patients’ education, income, and personality characteristics were considered. van Ryn and Burke (2000) - study conducted in actual clinical settings found that doctors are more likely to ascribe negative racial stereotypes to their minority patients. These stereotypes were ascribed to patients even when differences in minority and non-minority patients’ education, income, and personality characteristics were considered. Finucane and Carrese (1990) - Physicians more likely to make negative comments when discussing minority patients’ cases. Finucane and Carrese (1990) - Physicians more likely to make negative comments when discussing minority patients’ cases.

17. What is the Evidence that Physician Biases and Stereotypes may Influence the Clinical Encounter (cont’d)? Rathore et al. (2000) – found that medical students were more likely to evaluate a white male “patient” with symptoms of cardiac disease as having “definite” or “probable” angina, relative to a black female “patient” with objectively similar symptoms. Rathore et al. (2000) – found that medical students were more likely to evaluate a white male “patient” with symptoms of cardiac disease as having “definite” or “probable” angina, relative to a black female “patient” with objectively similar symptoms. Abreu (1999) – found that mental health professionals and trainees were more likely to evaluate a hypothetical patient more negatively after being “primed” with words associated with African American stereotypes. Abreu (1999) – found that mental health professionals and trainees were more likely to evaluate a hypothetical patient more negatively after being “primed” with words associated with African American stereotypes.

18. Among Medicare Beneficiaries Enrolled in Managed Care Plans, African Americans Receive Poorer Quality of Care (Schneider et al., JAMA, March 13, 2002

19. What are potential sources of disparities in care?  Health systems-level factors – financing, structure of care; cultural and linguistic barriers  Patient-level factors – including patient preferences, refusal of treatment, poor adherence, biological differences  Disparities arising from the clinical encounter

20. Differences are Real  Physicians hold stereotypes that affect treatment  Differences in treatment and outcome CANNOT be explained away by other factors  Bias and racism lead to real differences in the treatment and outcome of minorities

21. The National Coalition for Women with Heart Disease  38% of women and 25% of men will die within one year of a first recognized heart attack.  35% of women and 18% of men heart attack survivors will have another heart attack within six years.  46% of women and 22% of men heart attack survivors will be disabled with heart failure within six years.  Women are almost twice as likely as men to die after bypass surgery.  Women are less likely than men to receive beta-blockers, ACE inhibitors or even aspirin after a heart attack.

22. More women than men die of heart disease each year,  yet women receive only:  33% of angioplasties, stents and bypass surgeries  28% of inplantable defibrillators and  36% of open-heart surgeries  Women comprise only 25% of participants in all heart-related research studies.

23. Important Points to Consider  Social class (which relates to occupation) is the most important predictor of health outcomes.  Rates of disease and death differ between regions of the world.  Racism of health professionals explains differences in health care between whites and minorities.  Sexism leads to higher rates of death among women with respect to heart disease.