There's one important cause of poorer health outcomes for Americans with highly pigmented skin which is well established by research and easy to fix: inadequate vitamin D3 cholecalciferol.
At least it would be easy to fix if doctors were fully aware of the best research, and so recommended that everyone supplement vitamin D3 sufficiently to attain the level of circulating (in the bloodstream, and as measured in "vitamin D" blood tests) 25-hydroxyvitamin D which the immune system needs to function properly.
Our vitamin D3 is either ingested or produced in the skin by ultraviolet B light breaking a carbon ring in 7-dehydrocholesterol.
25-hydroxyvitamin D (calcifediol AKA "calcidiol") is produced, over several days, primarily in the liver by hydroxylating vitamin D3 at the 25th carbon to produce a different molecule. Neither vitamin D3 nor 25-hydroxyvitamin D are hormones.
The kidneys work fine with about 20 ng/mL (50 nmol/L) circulating 25-hydroxyvitamin D. This is 1 part in 50,000,000 by mass. Government health authorities and many doctors consider this to be a healthy level (concentration) of circulating 25-hydroxyvitamin D, but this is only for the well known function of the kidneys, which produce a very low level (0.05 to 0.1 ng/mL) of circulating calcitriol (1,25-dihydroxyvitamin D) which acts as a hormone (a long distance, blood-borne, signaling molecule) to affect the behavior of several cell types around the body which are involved in calcium-phosphate-bone metabolism.
These authorities and doctors are not yet properly aware of the research which shows that the multiple types of immune cell also rely on circulating 25-hydroxyvitamin D, as a raw material with which to run their intracrine (inside each individual cell) and paracrine (to nearby cells, often of different types) signaling systems, and that the immune system needs at least 50 ng/mL circulating 25-hydroxyvitamin D (125 nmol/L, 1 part in 20,000,000 by mass) to function properly. Please see my page https://vitamindstopscovid.info/00-evi/ for links to and discussion of the research which shows this very clearly.
There's almost no vitamin D3 in food, whether or not it is fortified with vitamin D or not (and fortification is usually with the less effective vitamin D2).
There's very little vitamin D3 in multivitamins - maybe 5 micrograms (200 IU).
Vitamin D3 can be produced in good quantities by the action of UV-B on ideally white skin, but this always damages DNA and so raises the risk of skin cancer. Such UV-B is only available naturally from high elevation sunlight on cloud-free days. So most people in the USA can't get enough of this all year round, even if they went to a lot of trouble to do so. They shouldn't, because such UV-B exposure, year after year, as would be required to attain at least 50 ng/mL circulating 25-hydroxyvitamin D would greatly raise their risk of skin cancer.
Melanin greatly reduces the ability of the skin to produce vitamin D3 in response to UV-B exposure. It also protects the skin from damage, including by absorbing most UV-B light before it can reach deep enough to damage DNA in cells.
Fortunately, we can easily get enough vitamin D3 as a supplement. 70 kg (154 lb) adults need about 1/8th of a milligram of supplemental vitamin D3 a day, on average, in order to attain (over several months) at least the 50 ng/mL circulating 25-hydroxyvitamin D they need for full immune system function.
This is 125 micrograms = 0.125 milligrams and is also known by the frighteningly high number of 5000 IUs ("International Units"). An IU is a cranky old unit from a century ago: 1/40,000,000 th of a gram of vitamin D3.
Without proper vitamin D3 supplementation, most people, including those with the whitest skin, cannot attain 50 ng/mL circulating 25-hydroxyvitamin D, except perhaps in summer if they get a lot of bare skin (no clothing, sunscreen or intervening glass) UV-B exposure.
So the health of the whole country is profoundly diminished by low -25-hydroxyvitamin D and the only way to fix this is by ingesting, for average weight adults 0.125 milligrams of vitamin D a day on average. This is a gram every 22 years. Vitamin D3 costs about USD$2.50 a gram ex-factory. A credit card weighs 5 grams.
Those who suffer from obesity need not just more vitamin D3 a day due to their higher body weight, but a higher amount than that due to obesity reducing the rate of hydroxylation to 25-hydroxyvitamin D and the excess adipose tissue absorbing more of this, and so keeping it out of circulation. (Research details: https://5nn.info/temp/250hd-obesity/.)
For recommendations (from New Jersey based Professor of Medicine Sunil Wimalawansa) on how much vitamin D3 to supplement, as a ratio of body weight - with higher ratios for those suffering from obesity - please see: https://vitamindstopscovid.info/00-evi/#00-how-much. These recommendations are now in a peer-reviewed journal article he wrote with another professor of medicine and a professor of pediatrics, all of them long-time vitamin D researchers: https://www.sciencedirect.com/science/article/pii/S2405844024107220.
These recommendations are intended to safely raise the circulating 25-hydroxyvitamin D level to at least 50 ng/mL, with no need for blood tests or medical monitoring.
"5000 IU"s sounds like a lot, but it is a tiny amount. Meanwhile, many doctors recommend only 1000 IU a day (a gram every 110 years) vitamin D3 supplementation, which may raise the 25-hydroxyvitamin D of average weight adults to about half of the 50 ng/mL needed for proper immune system function.
The health of white folks in the USA would be immensely improved by this proper vitamin D3 supplementation. The health of those with brown skin would be improved even more, since their health suffers more than that of Whites, due to their generally lower UV-B skin production of vitamin D3.
African Americans, Africans and other people with dark or black skin would benefit even more, since, without proper vitamin D3 supplementation, their health is even more blighted than other people with lighter skin.
The harm from inadequate vitamin D3 intake (supplements plus whatever is produced in the skin) starts before birth: https:// vitamindstopscovid.info/00-evi/#3.2, with preeclampsia, pre-term birth, sepsis and the later development of autism, ADHD, intellectual disability and schizophrenia. I recently wrote https://nutritionmatters.substack.com/p/proper-vitamin-d3-supplementation "Proper vitamin D3 supplementation: Pregnant women and their future children first!".
Inadequate 25-hydroxyvitamin D greatly increases the risk of severe disease (sepsis, COVID-19, ARDS, Kawasaki disease, MIS-C).
It greatly increases the risk of neurodegeneration. See the research cited at: https:// vitamindstopscovid.info/00-evi/#3.3 concerning Parkinson's disease, multiple system atrophy, dementia with Lewy bodies and other forms of dementia.
Prof. Wimalawansa told me that the most common objection he has from doctors regarding this research is: "How can it be true? Its too simple.". It is simple and it is true.
Very few people worldwide have sufficient 25-hydroxyvitamin D to run their immune system properly. Those who do get it from proper vitamin D3 supplementation, or arguably excessive sun exposure.
Many or most white people in the USA are in a terrible state due to inadequate vitamin D3 supplementation. Mexicans, Puerto Rican's have it worse. African Americans have it the worst of all. This explains a substantial fraction of the generally worse health of Blacks in the USA, compared to people with lighter skin.
Sometimes it feels as if the "anti-racists" never sleep and that their search for racial disparities is endless. I saw a PBS Newshour segment yesterday that highlighted a National Bureau of Economic Research working paper ("Drivers of Racial Differences in C-Sections") that said black mothers are 25% more likely to deliver by C-section than non-Hispanic white mothers:
I didn't find the PBS segment compelling because there was no "smoking gun" that proved racial bias was behind the the discrepancy. The NY Times reporter who was interviewed for the segment acknowledged that nobody knows for sure why black mothers are more likely to deliver their babies via C-section. Dr. Patel's essay prompted me to do a little digging, which confirmed my initial take.
The analysis was based upon the birth records of almost 1 million babies delivered in New Jersey between 2008 and 2017, The introduction section says 29.3% of white non-Hispanic mothers delivered by C-section compared to 34% of black mothers. In other words, 29 out of 100 white babies were delivered via C-section vs. 34 out of 100 black babies. You can convince yourself that this difference (< 5 babies per 100 deliveries) is meaningful and newsworthy or you can chalk it up to statistical "noise." The paper also said that the race and gender of the physician didn't impact the data. In other words, black doctors were just as likely to give black mothers C-sections as white doctors and female doctors were just as likely to give black mothers C-sections as male doctors.
Despite the lack of a "smoking gun," how one interprets this analysis is very dependent upon how you feel about race and racial disparities. This can't be overemphasized because a Pew Research paper from June said that 51% of black adults believe America's health care system was designed to hold black people back:
I'm not a doctor, but I'm skeptical that physicians in New Jersey were giving more C-sections to black mothers in order to drive additional revenue for their hospitals.
The headline confirms the suspicions of those who believe America's health care system is designed to hold black people back, but it prompts eye-rolling and thoughts of "Here we go again" for those who believe racism isn't a major factor in America today.
Dr. Patel's essay explains why the "health equity" agenda is bad. It seems unlikely, however, that it can be countered without building greater faith in our health care system.
P.S. Here's another take on the NBER working paper if you want a second opinion:
This is a good essay. I've done a lot of research in healthcare economics over the years, and I agree that health equity disparities don't necessarily mean that there are disparities in care. There are many subtleties in the data, and important data are often missing.
Anyone can subscribe for free to the Sensible Medicine substack, and I have a subscription. I think non-paying subscribers get access to all of the articles, but only paying subscribers can comment on the articles. In any event, this website shows their recent articles. The November 23 article by Vinay Prasad and Joseph Marine on 10 steps to reform NIH is another good article.
What makes me laugh is this language suggesting that racial health disparities don't "necessarily" or "automatically" point to systemic racism. As if we had a health care system that provides care based on racial criteria and as if the burden of proof didn't rest with the fools and liars who keep trotting this canony (that's a cross between a canard and a pony I just envisioned) out day after day without evidence and against all common sense perception. Health care is just one example. The only obvious racial discrimination I have encountered in over 35 years in this country is the reverse kind, which is everywhere, and I'm the kind of liberal who dumps on Lowry every chance I get for defending and voting for Trump. This canony passes a smell test no better than the stolen election lie of 2020 did. But here we are, in a world of mass delusions.
I'm a retired physician, trained at Grady Hospital in Atlanta, Ga. My favorite mentor was Hamilton Holmes, a Black orthopedic surgeon. I then worked in a small North Carolina town and sent my 3 children to public schools which were 60% Black. I must agree with Glenn that statistical differences do not automatically relate to "systemic racism". For example, the peri-natal complication rate is much higher among Black women. A NYT article claimed systemic racism when Serena Williams had a pulmonary embolus. Serena, like many Black women, had gained a lot of weight with her pregnancy. Any OB/GYN will tell you that increases blood pressure, glucose levels, and many other peri-natal complications result from being overweight. A study from the CDC showed that culturally, Black women have thought that gaining a lot of weight when pregnant resulted in healthier children, -- a social myth that remains. If one really wants to help decrease the peri-natal complications for Black women, one should compare social and physical habits for various groups during that time and see if there are any patterns. Study the issue scientifically rather than emotionally.
There's one important cause of poorer health outcomes for Americans with highly pigmented skin which is well established by research and easy to fix: inadequate vitamin D3 cholecalciferol.
At least it would be easy to fix if doctors were fully aware of the best research, and so recommended that everyone supplement vitamin D3 sufficiently to attain the level of circulating (in the bloodstream, and as measured in "vitamin D" blood tests) 25-hydroxyvitamin D which the immune system needs to function properly.
Our vitamin D3 is either ingested or produced in the skin by ultraviolet B light breaking a carbon ring in 7-dehydrocholesterol.
25-hydroxyvitamin D (calcifediol AKA "calcidiol") is produced, over several days, primarily in the liver by hydroxylating vitamin D3 at the 25th carbon to produce a different molecule. Neither vitamin D3 nor 25-hydroxyvitamin D are hormones.
The kidneys work fine with about 20 ng/mL (50 nmol/L) circulating 25-hydroxyvitamin D. This is 1 part in 50,000,000 by mass. Government health authorities and many doctors consider this to be a healthy level (concentration) of circulating 25-hydroxyvitamin D, but this is only for the well known function of the kidneys, which produce a very low level (0.05 to 0.1 ng/mL) of circulating calcitriol (1,25-dihydroxyvitamin D) which acts as a hormone (a long distance, blood-borne, signaling molecule) to affect the behavior of several cell types around the body which are involved in calcium-phosphate-bone metabolism.
These authorities and doctors are not yet properly aware of the research which shows that the multiple types of immune cell also rely on circulating 25-hydroxyvitamin D, as a raw material with which to run their intracrine (inside each individual cell) and paracrine (to nearby cells, often of different types) signaling systems, and that the immune system needs at least 50 ng/mL circulating 25-hydroxyvitamin D (125 nmol/L, 1 part in 20,000,000 by mass) to function properly. Please see my page https://vitamindstopscovid.info/00-evi/ for links to and discussion of the research which shows this very clearly.
There's almost no vitamin D3 in food, whether or not it is fortified with vitamin D or not (and fortification is usually with the less effective vitamin D2).
There's very little vitamin D3 in multivitamins - maybe 5 micrograms (200 IU).
Vitamin D3 can be produced in good quantities by the action of UV-B on ideally white skin, but this always damages DNA and so raises the risk of skin cancer. Such UV-B is only available naturally from high elevation sunlight on cloud-free days. So most people in the USA can't get enough of this all year round, even if they went to a lot of trouble to do so. They shouldn't, because such UV-B exposure, year after year, as would be required to attain at least 50 ng/mL circulating 25-hydroxyvitamin D would greatly raise their risk of skin cancer.
Melanin greatly reduces the ability of the skin to produce vitamin D3 in response to UV-B exposure. It also protects the skin from damage, including by absorbing most UV-B light before it can reach deep enough to damage DNA in cells.
Fortunately, we can easily get enough vitamin D3 as a supplement. 70 kg (154 lb) adults need about 1/8th of a milligram of supplemental vitamin D3 a day, on average, in order to attain (over several months) at least the 50 ng/mL circulating 25-hydroxyvitamin D they need for full immune system function.
This is 125 micrograms = 0.125 milligrams and is also known by the frighteningly high number of 5000 IUs ("International Units"). An IU is a cranky old unit from a century ago: 1/40,000,000 th of a gram of vitamin D3.
Without proper vitamin D3 supplementation, most people, including those with the whitest skin, cannot attain 50 ng/mL circulating 25-hydroxyvitamin D, except perhaps in summer if they get a lot of bare skin (no clothing, sunscreen or intervening glass) UV-B exposure.
So the health of the whole country is profoundly diminished by low -25-hydroxyvitamin D and the only way to fix this is by ingesting, for average weight adults 0.125 milligrams of vitamin D a day on average. This is a gram every 22 years. Vitamin D3 costs about USD$2.50 a gram ex-factory. A credit card weighs 5 grams.
Those who suffer from obesity need not just more vitamin D3 a day due to their higher body weight, but a higher amount than that due to obesity reducing the rate of hydroxylation to 25-hydroxyvitamin D and the excess adipose tissue absorbing more of this, and so keeping it out of circulation. (Research details: https://5nn.info/temp/250hd-obesity/.)
For recommendations (from New Jersey based Professor of Medicine Sunil Wimalawansa) on how much vitamin D3 to supplement, as a ratio of body weight - with higher ratios for those suffering from obesity - please see: https://vitamindstopscovid.info/00-evi/#00-how-much. These recommendations are now in a peer-reviewed journal article he wrote with another professor of medicine and a professor of pediatrics, all of them long-time vitamin D researchers: https://www.sciencedirect.com/science/article/pii/S2405844024107220.
These recommendations are intended to safely raise the circulating 25-hydroxyvitamin D level to at least 50 ng/mL, with no need for blood tests or medical monitoring.
"5000 IU"s sounds like a lot, but it is a tiny amount. Meanwhile, many doctors recommend only 1000 IU a day (a gram every 110 years) vitamin D3 supplementation, which may raise the 25-hydroxyvitamin D of average weight adults to about half of the 50 ng/mL needed for proper immune system function.
The health of white folks in the USA would be immensely improved by this proper vitamin D3 supplementation. The health of those with brown skin would be improved even more, since their health suffers more than that of Whites, due to their generally lower UV-B skin production of vitamin D3.
African Americans, Africans and other people with dark or black skin would benefit even more, since, without proper vitamin D3 supplementation, their health is even more blighted than other people with lighter skin.
The harm from inadequate vitamin D3 intake (supplements plus whatever is produced in the skin) starts before birth: https:// vitamindstopscovid.info/00-evi/#3.2, with preeclampsia, pre-term birth, sepsis and the later development of autism, ADHD, intellectual disability and schizophrenia. I recently wrote https://nutritionmatters.substack.com/p/proper-vitamin-d3-supplementation "Proper vitamin D3 supplementation: Pregnant women and their future children first!".
Inadequate 25-hydroxyvitamin D greatly increases the risk of severe disease (sepsis, COVID-19, ARDS, Kawasaki disease, MIS-C).
It greatly increases the risk of neurodegeneration. See the research cited at: https:// vitamindstopscovid.info/00-evi/#3.3 concerning Parkinson's disease, multiple system atrophy, dementia with Lewy bodies and other forms of dementia.
Prof. Wimalawansa told me that the most common objection he has from doctors regarding this research is: "How can it be true? Its too simple.". It is simple and it is true.
Very few people worldwide have sufficient 25-hydroxyvitamin D to run their immune system properly. Those who do get it from proper vitamin D3 supplementation, or arguably excessive sun exposure.
Many or most white people in the USA are in a terrible state due to inadequate vitamin D3 supplementation. Mexicans, Puerto Rican's have it worse. African Americans have it the worst of all. This explains a substantial fraction of the generally worse health of Blacks in the USA, compared to people with lighter skin.
Sometimes it feels as if the "anti-racists" never sleep and that their search for racial disparities is endless. I saw a PBS Newshour segment yesterday that highlighted a National Bureau of Economic Research working paper ("Drivers of Racial Differences in C-Sections") that said black mothers are 25% more likely to deliver by C-section than non-Hispanic white mothers:
https://www.youtube.com/watch?v=Tr19P1TVd6E
https://www.nber.org/papers/w32891
I didn't find the PBS segment compelling because there was no "smoking gun" that proved racial bias was behind the the discrepancy. The NY Times reporter who was interviewed for the segment acknowledged that nobody knows for sure why black mothers are more likely to deliver their babies via C-section. Dr. Patel's essay prompted me to do a little digging, which confirmed my initial take.
The analysis was based upon the birth records of almost 1 million babies delivered in New Jersey between 2008 and 2017, The introduction section says 29.3% of white non-Hispanic mothers delivered by C-section compared to 34% of black mothers. In other words, 29 out of 100 white babies were delivered via C-section vs. 34 out of 100 black babies. You can convince yourself that this difference (< 5 babies per 100 deliveries) is meaningful and newsworthy or you can chalk it up to statistical "noise." The paper also said that the race and gender of the physician didn't impact the data. In other words, black doctors were just as likely to give black mothers C-sections as white doctors and female doctors were just as likely to give black mothers C-sections as male doctors.
Despite the lack of a "smoking gun," how one interprets this analysis is very dependent upon how you feel about race and racial disparities. This can't be overemphasized because a Pew Research paper from June said that 51% of black adults believe America's health care system was designed to hold black people back:
https://www.pewresearch.org/race-and-ethnicity/2024/06/15/most-black-americans-believe-u-s-institutions-were-designed-to-hold-black-people-back/
The gender breakdown was 44% for black men and 58% for black women (See Section 6 for details).
The NY Times reporter interviewed by PBS wrote a piece that suggested both race and economics help explain the disparity. Here's the headline:
Doctors Give Black Women Unneeded C-Sections to Fill Operating Rooms, Study Suggests
https://www.nytimes.com/2024/09/10/health/cesarean-sections-black-women.html
I'm not a doctor, but I'm skeptical that physicians in New Jersey were giving more C-sections to black mothers in order to drive additional revenue for their hospitals.
The headline confirms the suspicions of those who believe America's health care system is designed to hold black people back, but it prompts eye-rolling and thoughts of "Here we go again" for those who believe racism isn't a major factor in America today.
Dr. Patel's essay explains why the "health equity" agenda is bad. It seems unlikely, however, that it can be countered without building greater faith in our health care system.
P.S. Here's another take on the NBER working paper if you want a second opinion:
https://www.acsh.org/news/2024/09/23/c-sections-cash-and-racial-bias-labor-and-delivery-more-color-coded-we-thought
That race card is really getting dog eared.
This is a good essay. I've done a lot of research in healthcare economics over the years, and I agree that health equity disparities don't necessarily mean that there are disparities in care. There are many subtleties in the data, and important data are often missing.
Anyone can subscribe for free to the Sensible Medicine substack, and I have a subscription. I think non-paying subscribers get access to all of the articles, but only paying subscribers can comment on the articles. In any event, this website shows their recent articles. The November 23 article by Vinay Prasad and Joseph Marine on 10 steps to reform NIH is another good article.
https://www.sensible-med.com/
What makes me laugh is this language suggesting that racial health disparities don't "necessarily" or "automatically" point to systemic racism. As if we had a health care system that provides care based on racial criteria and as if the burden of proof didn't rest with the fools and liars who keep trotting this canony (that's a cross between a canard and a pony I just envisioned) out day after day without evidence and against all common sense perception. Health care is just one example. The only obvious racial discrimination I have encountered in over 35 years in this country is the reverse kind, which is everywhere, and I'm the kind of liberal who dumps on Lowry every chance I get for defending and voting for Trump. This canony passes a smell test no better than the stolen election lie of 2020 did. But here we are, in a world of mass delusions.
I'm a retired physician, trained at Grady Hospital in Atlanta, Ga. My favorite mentor was Hamilton Holmes, a Black orthopedic surgeon. I then worked in a small North Carolina town and sent my 3 children to public schools which were 60% Black. I must agree with Glenn that statistical differences do not automatically relate to "systemic racism". For example, the peri-natal complication rate is much higher among Black women. A NYT article claimed systemic racism when Serena Williams had a pulmonary embolus. Serena, like many Black women, had gained a lot of weight with her pregnancy. Any OB/GYN will tell you that increases blood pressure, glucose levels, and many other peri-natal complications result from being overweight. A study from the CDC showed that culturally, Black women have thought that gaining a lot of weight when pregnant resulted in healthier children, -- a social myth that remains. If one really wants to help decrease the peri-natal complications for Black women, one should compare social and physical habits for various groups during that time and see if there are any patterns. Study the issue scientifically rather than emotionally.