It is well known that racial bias is built in to the medical system. Black patients with kidney disease were evaluated by a blood test that specifically targeted Black patients. The test made it less likely that Black patients would be referred for dialysis.
Narratives often trump facts when it comes to these kinds of debates. Here are life expectancies (both sexes) from the CDC, at birth and by race, as of 2019:
The black-white gap (3.5 years) is roughly comparable to the white-Hispanic gap (3,1 years). It's not clear how those who argue that the black-white gap is driven by racism can reconcile the white-Hispanic gap, let alone the larger gaps between Asians and other groups.
Arguments over the gaps between blacks and whites are often contentious and misguided when the real question should be why do Asians and Hispanics, two groups that don't seem to have a lot in common, live so much longer than their peers?
Even larger gaps in life expectancies are present if you look at educational attainment. Economists Anne Case and Angus Deaton (a Nobel laureate) published a paper for Brookings in 2023 that said college graduates lived 8.5 years longer than those without a bachelor's degree as of 2021. That's up from a gap of 2.5 years in 1992:
Physicians who want to have the greatest impact on society should focus on life expectancy gaps, by educational attainment, which are larger, worsening, and impact more people (two-thirds of American adults don't have bachelor's degrees), than life expectancy gaps by race.
But we'd want to be sure we did not confuse correlation with causation.....and I strongly suspect the correlation between educational attainment and life expectancy is simply the inevitable yield of the causal link between individual behavior and medical condition.
The simple fact of either having or not having a diploma is irrelevant to one's health....but our behavior is critical, regardless of sheepskin. Is our diet good? Do we exercise appropriately? Do we get regular check-ups? Do we engage in high-risk activities (smoking, drinking to excess, use of narcotics, or psychotropics, driving without a seatbelt, riding a motorcycle, speeding, engaging in criminal activity). Are we obese? etc.
Given those obvious drivers to bad health & generally lower life expectancy -- which, of course, are generally correlated with personal attitudes that either value or dismiss higher educational attainment -- I would suggest that medical doctors are not the ones who should focus on this life expectancy gap, but sociologists & psychologists.
Doctors have been telling us for generations that smoking kills us. And yet.... 32M of us still smoke. There is, of course, a strong inverse correlation between smoking and education level, but again -- it's not the diploma which causes one to engage in an activity which is fundamentally suicidal, it's our attitude, our interests, and our desires.
And -- if we push this question a little harder -- if I voluntarily choose to behave in a high-risk manner, making life choices that work to shorten my life span.... why would anyone (doctor, sociologist, psychologist, et al) work (or want to work) to push me to make healthier decisions that I purposely choose not to make?
You make a good point about correlation not proving causation. That's the point I was trying to make by showing the gaps across racial groups. They don't fit the racism narrative.
The life expectancy gap by educational attainment is complicated. Case and Deaton coined the phrase "deaths of despair" when making the argument that a lot of blue collar workers in economically depressed areas were using tobacco, alcohol, and illicit drugs more than most Americans in response to their lack of economic opportunities and this caused lower life expectancies for them. The effect that Case and Deaton measured was so large that it depressed life expectancies for America as a whole for several years before the pandemic hit. Obama was intrigued by their findings and invited them to the White House to discuss their analysis.
There seems to be a connection between education and life expectancy. The University of Washington's Medical School issued a report in January that said college graduates live 11 years longer than those who don't finish high school:
Here are the life expectancies they reported, by education level:
College graduates - 84.2 years
Those who completed some college - 82.1 years
High school graduates - 77.3 years
Those who didn't finish high school - 73.5 years
Here's an excerpt from the analysis:
“In the US, more formal education often translates to better employment opportunities, including higher-paying jobs that have fewer health risks,” said the study’s senior author and IHME Associate Professor Laura Dwyer-Lindgren. “This puts people in a better position to build a healthy life and, when needed, obtain high-quality health care.”
Decide for yourself if that's a compelling rationale that explains the patterns in the data.
My take is that these kinds of analyses identify problems that society should consider tackling, but they don't provide solutions. Groups of people with various forms of expertise are needed to identify the root causes of problems and to recommend ideas for solving them.
You ignore use of biased “correction factors” that delayed diagnosis of severe renal and pulmonary disease in Black patients. You also ignore a plethora of studies suggesting Black patients received less access to advanced medical care for severe illnesses despite equal economic and insurance status.
It seems you are cherry-picking data to fit a personal bias.
Life expectancies are the ultimate measure of how well our health care system treats people. Do you think it's biased towards Asians and Hispanics? Is there something about their genetics that helps them live longer? Or are there things about their diets, lifestyles, etc. that help them live longer? A combination?
I'm all for rooting out bias, but the numbers speak for themselves. There are bigger factors at play when it comes to life expectancies.
It was soon after the shots were made available, for the first threat. And, then, it was soon after the boosters were released, for the second. I should note, he routinely engaged her in political discussions and expressed his disgust for Trump. He’s a doc in Boston.
Like so many things these days, it seems incredibly idiotic to have to begin by saying that Doctors are Doctors (PERIOD!) but evidently we must. Equally we might also emphasize the converse...that Doctors are not Plumbers...or Carpenters... Electricians... Economics Profs.... Foreign Policy Advisers.... Experts in Industrial Roofing... or (do we even need to say it?) Political Activists waving nicely embossed Social Justice signs.
Certainly they can play around with those other things, if that's something they enjoy doing. Hobbies are hobbies, after all. But hobbies have no place in the Operating Theater. I don't care if my heart surgeon really enjoys coin collecting, I don't want to hear about his collection when my immediate & exclusive interest is clearing an arterial blockage before I die.
Satel & Huddle are right....but they're not 'enough' right. They suggest, "for individual doctors who wish to responsibly leverage their professional standing to effect political change," that there are '3 Guidelines' that should be followed. NO. Individual doctors CANNOT and MUST NOT leverage their professional standing to effect political change, at all, ever! Their professional standing is medical in nature; their expertise is in blood flow, or kidney function, or tumor removal. None of those things has anything at all to do with 'political change'. Nor should the individual's preference for political change have anything to do with kidney function.
There can be no 'political advocacy' causes in the Oncology Intensive Care Unit. It doesn't matter how much the individual physician is sure that their electoral preferences would 'help' their patients, the answer to any and all political advocacy questions is still NO.
But keeping sign-waving out of the Neo Natal ward is not sufficient. This refusal must extend all the way back to Medical School and the Admissions Process which leads to medical school.
Consider the Life Flight which brought you to the Emergency Room.... consider the blood, the pain, the 'worst case' outcome... and then ask yourself, which message do you want to hear, right then, as they wheel you into surgery? "Don't worry, we have the most Diverse, the most Inclusive, the most Equitably chosen surgical team possible. We have heterosexuals and homosexuals and 13% Blacks and 40% obese and 51% women waiting there in their blue gowns holding scalpels (and don't ask about their Mdcat scores).
OR -- do you want to hear: 'Don't worry, we have the best damned surgical team possible!'
We all know the answer; we should never pretend that we don't. And it doesn't matter at all if that Very Best Surgical Team looks alike, sounds alike, dresses alike, and graduated with the same 4.0 GPA. What we care about is living.
See a related essay "'Combat Racism' But Not Like This" by Jeffrey Flier, former Dean of the Harvard Medical School that appeared in the Free Press 2-7-24, where as an alumni he critiques DEI initiatives at the Mt Sinai School of Medicine in New York. From my experience, the Mt. Sinai Hospital system, rated at one of the best in the country, adopted "Fight Racism" as its mantra, but after 2020 the system lost many of its staff and its attendings failed to diagnose my companion's illness. I eventually lost confidence, sought second opinion from physicians at Presbyterian Hospital who diagnosed her illness, but it was to late. I blame myself for not leaving Mt. Sinai sooner. I have friends who experienced similar failures.
A very chilling essay. Makes me think of a couple of news articles over the last year or two, in which health care professionals had actually tried to cause harm to patients whose politics these doctors or nurses disagreed with. I mean harm done through medical care. This is a very dark and scary path to go down. Let's hope the poltical/social climate is changing, and this will vanish before it can do much more harm.
I guess I am very surprised by this because Uche Blackstock on her social media has made health equity seem like the equivalent of building good cottages. But she has a relentless focus on patients and POC health professionals and outcomes that concretely affect their well-being.
Critiques of the wokeness of the American medical profession have been made by individuals such as Heather MacDonald in her recent book When Race Trumps Merit and also frequently by Amy Wax, who in particular seems to direct her ire towards the phenomenon of woke South Asian women in medicine. Although these criticisms are certainly valid and important, I'd like to focus the spotlight on an under-appreciated and arguably more important aspect of wokeness in American medicine.
As the comment above details, in recent years scores of Chinese American academics have been shoddily accused of using NIH funding to supposedly advance research in China or of holding positions with and accepting grants from Chinese institutions. In some cases preeminent individuals in their fields were essentially forced out of their positions in the US and as a result decided to relocate to China to continue their work instead. I find it truly amazing that the NIH can on the one hand trumpet its commitment to anti-racism and DEI and on the other destroy people's careers simply because those individuals were Chinese.
Just as in my opinion, by focusing on the racial angle of sympathy for brown-skinned Palestinians rising up against their white Jewish oppressors, we end up missing the more interesting phenomenon of America First vs Israel First within MAGA, by focusing primarily on the DEI angle of wokeness in American medicine, we also end up missing the far more relevant narrative of 21st century American geopolitical wokeness. Traditionally America has been very strong in the life sciences and medicine, whereas the rise of competitors in East Asia has had a distinct focus on the physical sciences and engineering. By pushing out individuals in the very areas where we're strongest, America is literally shooting itself in the foot in ways far more deleterious than any George Floyd motivated struggle session. When all is said and done, it may very well prove to be the case that American science becoming overly geopolitical hurt this country far more than American science becoming racially political ever did.
It is well known that racial bias is built in to the medical system. Black patients with kidney disease were evaluated by a blood test that specifically targeted Black patients. The test made it less likely that Black patients would be referred for dialysis.
https://medicine.yale.edu/news-article/abandoning-a-race-biased-tool-for-kidney-diagnosis/
A similar race based correction led to missed diagnosis of severe pulmonary disease in Black patients
https://www.thoracic.org/about/newsroom/press-releases/conference/removal-of-race-correction-in-pulmonary-function-tests.php
There is research that suggests racial differences persist despite equal educational levels.
https://www.sciencedirect.com/science/article/pii/S235282732200115X#:~:text=Woolf%20et%20al.,et%20al.%2C%202007).
In advanced heart failure, for example Black patients are less likely to receive left ventricular assist devices or to be referred for transplant
https://www.nih.gov/news-events/news-releases/nih-supported-study-finds-racial-disparities-advanced-heart-failure-treatment
The tendency at this site is to rapidly remove race as a factor in any and every situation.
Excellent article. Woke ideology has no place in medicine
Very thoughtful. I'm saving this one for a rainy day argument.
Excellent post, thank you!
Narratives often trump facts when it comes to these kinds of debates. Here are life expectancies (both sexes) from the CDC, at birth and by race, as of 2019:
https://www.cdc.gov/nchs/hus/data-finder.htm?&subject=Life%20expectancy
All races - 78.8 years
Asian, not-Hispanic - 85.6 years
Black, not-Hispanic -75.3 years
Hispanic - 81.9 years
White, not-Hispanic - 78.8 years
The black-white gap (3.5 years) is roughly comparable to the white-Hispanic gap (3,1 years). It's not clear how those who argue that the black-white gap is driven by racism can reconcile the white-Hispanic gap, let alone the larger gaps between Asians and other groups.
Arguments over the gaps between blacks and whites are often contentious and misguided when the real question should be why do Asians and Hispanics, two groups that don't seem to have a lot in common, live so much longer than their peers?
Even larger gaps in life expectancies are present if you look at educational attainment. Economists Anne Case and Angus Deaton (a Nobel laureate) published a paper for Brookings in 2023 that said college graduates lived 8.5 years longer than those without a bachelor's degree as of 2021. That's up from a gap of 2.5 years in 1992:
https://www.brookings.edu/articles/accounting-for-the-widening-mortality-gap-between-american-adults-with-and-without-a-ba/
Physicians who want to have the greatest impact on society should focus on life expectancy gaps, by educational attainment, which are larger, worsening, and impact more people (two-thirds of American adults don't have bachelor's degrees), than life expectancy gaps by race.
-
Interesting point.
But we'd want to be sure we did not confuse correlation with causation.....and I strongly suspect the correlation between educational attainment and life expectancy is simply the inevitable yield of the causal link between individual behavior and medical condition.
The simple fact of either having or not having a diploma is irrelevant to one's health....but our behavior is critical, regardless of sheepskin. Is our diet good? Do we exercise appropriately? Do we get regular check-ups? Do we engage in high-risk activities (smoking, drinking to excess, use of narcotics, or psychotropics, driving without a seatbelt, riding a motorcycle, speeding, engaging in criminal activity). Are we obese? etc.
Given those obvious drivers to bad health & generally lower life expectancy -- which, of course, are generally correlated with personal attitudes that either value or dismiss higher educational attainment -- I would suggest that medical doctors are not the ones who should focus on this life expectancy gap, but sociologists & psychologists.
Doctors have been telling us for generations that smoking kills us. And yet.... 32M of us still smoke. There is, of course, a strong inverse correlation between smoking and education level, but again -- it's not the diploma which causes one to engage in an activity which is fundamentally suicidal, it's our attitude, our interests, and our desires.
And -- if we push this question a little harder -- if I voluntarily choose to behave in a high-risk manner, making life choices that work to shorten my life span.... why would anyone (doctor, sociologist, psychologist, et al) work (or want to work) to push me to make healthier decisions that I purposely choose not to make?
You make a good point about correlation not proving causation. That's the point I was trying to make by showing the gaps across racial groups. They don't fit the racism narrative.
The life expectancy gap by educational attainment is complicated. Case and Deaton coined the phrase "deaths of despair" when making the argument that a lot of blue collar workers in economically depressed areas were using tobacco, alcohol, and illicit drugs more than most Americans in response to their lack of economic opportunities and this caused lower life expectancies for them. The effect that Case and Deaton measured was so large that it depressed life expectancies for America as a whole for several years before the pandemic hit. Obama was intrigued by their findings and invited them to the White House to discuss their analysis.
There seems to be a connection between education and life expectancy. The University of Washington's Medical School issued a report in January that said college graduates live 11 years longer than those who don't finish high school:
https://www.healthdata.org/news-events/newsroom/news-releases/us-college-graduates-live-average-11-years-longer-those-who
Here are the life expectancies they reported, by education level:
College graduates - 84.2 years
Those who completed some college - 82.1 years
High school graduates - 77.3 years
Those who didn't finish high school - 73.5 years
Here's an excerpt from the analysis:
“In the US, more formal education often translates to better employment opportunities, including higher-paying jobs that have fewer health risks,” said the study’s senior author and IHME Associate Professor Laura Dwyer-Lindgren. “This puts people in a better position to build a healthy life and, when needed, obtain high-quality health care.”
Decide for yourself if that's a compelling rationale that explains the patterns in the data.
My take is that these kinds of analyses identify problems that society should consider tackling, but they don't provide solutions. Groups of people with various forms of expertise are needed to identify the root causes of problems and to recommend ideas for solving them.
You ignore use of biased “correction factors” that delayed diagnosis of severe renal and pulmonary disease in Black patients. You also ignore a plethora of studies suggesting Black patients received less access to advanced medical care for severe illnesses despite equal economic and insurance status.
It seems you are cherry-picking data to fit a personal bias.
How am I cherry-picking data? The life expectancy numbers I provided are at the macro level and represent all Americans.
You leave out other factors that play a role in poor outcomes.
Life expectancies are the ultimate measure of how well our health care system treats people. Do you think it's biased towards Asians and Hispanics? Is there something about their genetics that helps them live longer? Or are there things about their diets, lifestyles, etc. that help them live longer? A combination?
I'm all for rooting out bias, but the numbers speak for themselves. There are bigger factors at play when it comes to life expectancies.
Fascinating and insightful information.
Thanks!
My wife’s rheumatologist told her he would not treat her if she didn’t get the vaccine, including the booster.
Wow. When was that? Recently?
It was soon after the shots were made available, for the first threat. And, then, it was soon after the boosters were released, for the second. I should note, he routinely engaged her in political discussions and expressed his disgust for Trump. He’s a doc in Boston.
I'm so sorry. Just icky.
Yabbut...
Like so many things these days, it seems incredibly idiotic to have to begin by saying that Doctors are Doctors (PERIOD!) but evidently we must. Equally we might also emphasize the converse...that Doctors are not Plumbers...or Carpenters... Electricians... Economics Profs.... Foreign Policy Advisers.... Experts in Industrial Roofing... or (do we even need to say it?) Political Activists waving nicely embossed Social Justice signs.
Certainly they can play around with those other things, if that's something they enjoy doing. Hobbies are hobbies, after all. But hobbies have no place in the Operating Theater. I don't care if my heart surgeon really enjoys coin collecting, I don't want to hear about his collection when my immediate & exclusive interest is clearing an arterial blockage before I die.
Satel & Huddle are right....but they're not 'enough' right. They suggest, "for individual doctors who wish to responsibly leverage their professional standing to effect political change," that there are '3 Guidelines' that should be followed. NO. Individual doctors CANNOT and MUST NOT leverage their professional standing to effect political change, at all, ever! Their professional standing is medical in nature; their expertise is in blood flow, or kidney function, or tumor removal. None of those things has anything at all to do with 'political change'. Nor should the individual's preference for political change have anything to do with kidney function.
There can be no 'political advocacy' causes in the Oncology Intensive Care Unit. It doesn't matter how much the individual physician is sure that their electoral preferences would 'help' their patients, the answer to any and all political advocacy questions is still NO.
But keeping sign-waving out of the Neo Natal ward is not sufficient. This refusal must extend all the way back to Medical School and the Admissions Process which leads to medical school.
Consider the Life Flight which brought you to the Emergency Room.... consider the blood, the pain, the 'worst case' outcome... and then ask yourself, which message do you want to hear, right then, as they wheel you into surgery? "Don't worry, we have the most Diverse, the most Inclusive, the most Equitably chosen surgical team possible. We have heterosexuals and homosexuals and 13% Blacks and 40% obese and 51% women waiting there in their blue gowns holding scalpels (and don't ask about their Mdcat scores).
OR -- do you want to hear: 'Don't worry, we have the best damned surgical team possible!'
We all know the answer; we should never pretend that we don't. And it doesn't matter at all if that Very Best Surgical Team looks alike, sounds alike, dresses alike, and graduated with the same 4.0 GPA. What we care about is living.
And DIEing is Death.
Dear Professor Loury
See a related essay "'Combat Racism' But Not Like This" by Jeffrey Flier, former Dean of the Harvard Medical School that appeared in the Free Press 2-7-24, where as an alumni he critiques DEI initiatives at the Mt Sinai School of Medicine in New York. From my experience, the Mt. Sinai Hospital system, rated at one of the best in the country, adopted "Fight Racism" as its mantra, but after 2020 the system lost many of its staff and its attendings failed to diagnose my companion's illness. I eventually lost confidence, sought second opinion from physicians at Presbyterian Hospital who diagnosed her illness, but it was to late. I blame myself for not leaving Mt. Sinai sooner. I have friends who experienced similar failures.
A very chilling essay. Makes me think of a couple of news articles over the last year or two, in which health care professionals had actually tried to cause harm to patients whose politics these doctors or nurses disagreed with. I mean harm done through medical care. This is a very dark and scary path to go down. Let's hope the poltical/social climate is changing, and this will vanish before it can do much more harm.
I guess I am very surprised by this because Uche Blackstock on her social media has made health equity seem like the equivalent of building good cottages. But she has a relentless focus on patients and POC health professionals and outcomes that concretely affect their well-being.
Critiques of the wokeness of the American medical profession have been made by individuals such as Heather MacDonald in her recent book When Race Trumps Merit and also frequently by Amy Wax, who in particular seems to direct her ire towards the phenomenon of woke South Asian women in medicine. Although these criticisms are certainly valid and important, I'd like to focus the spotlight on an under-appreciated and arguably more important aspect of wokeness in American medicine.
https://glennloury.substack.com/p/heather-mac-donald-when-race-trumps/comment/15474209
As the comment above details, in recent years scores of Chinese American academics have been shoddily accused of using NIH funding to supposedly advance research in China or of holding positions with and accepting grants from Chinese institutions. In some cases preeminent individuals in their fields were essentially forced out of their positions in the US and as a result decided to relocate to China to continue their work instead. I find it truly amazing that the NIH can on the one hand trumpet its commitment to anti-racism and DEI and on the other destroy people's careers simply because those individuals were Chinese.
Just as in my opinion, by focusing on the racial angle of sympathy for brown-skinned Palestinians rising up against their white Jewish oppressors, we end up missing the more interesting phenomenon of America First vs Israel First within MAGA, by focusing primarily on the DEI angle of wokeness in American medicine, we also end up missing the far more relevant narrative of 21st century American geopolitical wokeness. Traditionally America has been very strong in the life sciences and medicine, whereas the rise of competitors in East Asia has had a distinct focus on the physical sciences and engineering. By pushing out individuals in the very areas where we're strongest, America is literally shooting itself in the foot in ways far more deleterious than any George Floyd motivated struggle session. When all is said and done, it may very well prove to be the case that American science becoming overly geopolitical hurt this country far more than American science becoming racially political ever did.
https://www.economist.com/science-and-technology/2024/06/12/china-has-become-a-scientific-superpower