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The Health 202: Black patients are less likely to face discrimination from black doctors

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with Paulina Firozi

Black Americans are more likely to get better medical care from black doctors and nurses, research shows.

But hospitals and physician offices trying to intentionally pair the two can face tricky legal questions.

As the nation focuses on disparities in the treatment of black Americans, some activists and politicians are calling for actions to specifically designed to help African Americans get health coverage and receive better-quality medical care — two areas in which they’ve traditionally lagged behind white patients.

The coronavirus pandemic has highlighted the vulnerability of black Americans, who are 3.6 times more likely than whites to die of covid-19. In Atlanta, for example, nearly 80 percent of patients hospitalized with the disease were black, according to a report by the Centers for Disease Control and Prevention.

Hiring of more black staff members at area hospitals was among a list of “demands” posted last week by occupiers of a protest zone in Seattle’s Capitol Hill neighborhood — a six-block area the police have abandoned as protesters turned it into an activist commune.

“We demand the hospitals and care facilities of Seattle employ black doctors and nurses specifically to help care for black patients,” the Medium post says.

But medical facilities can’t hire providers of a certain race specifically to treat patients of a certain race.

That would be considered segregation in the eyes of the law, according to Kimani Paul-Emile, professor of law at Fordham University and associate director of its Center on Race, Law and Justice.

There is legal room for patients to turn down treatment, including treatment from a particular doctor, she said. Legal grounds are especially strong for patients to reject treatment from a certain doctor on health grounds — such as if a woman who survived sexual assault doesn’t want to see a male doctor, for example. 

But a hospital could face a lawsuit based on Title VII of the Civil Rights Act if it is continually turning down opportunities for certain doctors to see patients, based on patient requests. In that case, the hospital could be found guilty of employment discrimination.

And hospitals must also consider the 1986 Emergency Medical Treatment and Labor Act, which requires them to screen and stabilize every patient who shows up at their door, regardless of their ability to pay. So if an emergency room patient rejects or demands care from a certain provider based on race, hospitals must balance those two legal obligations.

“They are sort of damned if they do, damned if they don’t,” Paul-Emile said.

There are, however, legal ways to try to improve health outcomes for black Americans.

Kentucky Gov. Andy Beshear (D) has vowed to get health insurance to “100 percent of our individuals in our black and African American communities” through a “multifaceted campaign.” Six percent of blacks in Kentucky are uninsured, a rate equal to that of whites in the state.

“We’ve done something like this in the past when we expanded Medicaid,” Beshear said in a subsequent NPR interview. “… But what’s different this time is our absolute priority on making sure we cover our black and African American Kentuckians first because of historic inequality.”

Beshear wasn’t proposing to provide health insurance programs only to black people. Instead, he was promising to help more African Americans sign up for Medicaid and the private health insurance marketplaces — programs available to everyone who meets certain income thresholds.

Hospitals and doctors' offices can also train and employ more black providers to care for all their patients.

Just 5 percent of doctors in the United States are black, even though 13 percent of the population is black.

Studies have repeatedly shown racial bias can affect how white doctors interact with black patients. That’s particularly true when it comes to assessing and treating reported pain. Two decades of published research found African American patients reporting pain were 22 percent less likely than white patients to get pain medication from their doctors, according to an analysis published in 2012.

The problem can be eased somewhat through what’s known as racial concordance — when a patient and a physician have a shared identity. Racial concordance can help counter bias and stereotyping, leading to better outcomes for the patient, Paul-Emile said. 

She stressed that always pairing patients with a doctor of the same race shouldn’t be the goal. But the practice has shown some benefits for some patients, especially those who are racial or ethnic minorities.

“For some patients, they have had poor experiences with a white doctor who doesn’t share their own racial and ethnic backgrounds,” she said.

Note to readers: The Health 202 will not publish Friday in honor of Juneteenth, the observance of the end of slavery in the United States. Here's an explainer by Karen Attiah, Washington Post Global Opinions editor, about the significance of the holiday. 

Ahh, oof and ouch

AHH: Tulsa’s Republican mayor said he's “not positive" about the safety of attending President Trump's political rally on Saturday.

Mayor G.T. Bynum called it an “honor” to welcome President Trump but urged attendees of his campaign rally to take needed precautions at a time when coronavirus cases are surging in Oklahoma.

“I’m not positive that everything is safe” Bynum said at a news conference yesterday. He said he did not plan to attend Trump’s Saturday event, and said the company managing the venue has “sole discretion” on whether to host the rally, adding that it was “not my decision to make.”

Some in Tulsa have called on the mayor to cancel the rally, scheduled to take place indoors at the 19,000-seat BOK Center. Tulsa Health Department Director Bruce Dart has called for the event to be postponed “until it’s safer.”

Some business owners, residents, and civil rights activists “say his visit — the first large-scale gathering in the state since its shutdown — will spread the novel coronavirus at a time when cases are spiking,” Joshua Partlow, Annie Gowen and DeNeen L. Brown report

At a news briefing yesterday, White House press secretary Kayleigh McEnany said supporters attending the president’s rallies “assume a personal risk.” 

“When you come to the rally, as with any event, you assume a personal risk. That is just what you do,” she said, adding there would be temperature checks as well as hand sanitizer and mask distribution. 

“When you go to a baseball game, you assume a risk. That’s part of life,” McEnany added. “It’s the personal decision of Americans as to whether to go to the rally or whether not to go to the rally.”

McEnany criticized the media for “hypocrisy” in how it reported on Trump's planned rally (which is indoor) versus a march for black transgender people in New York City last weekend (which was outdoor).

“McEnany refused to answer whether the administration thought indoor events and outdoor protests carried the same amount of risk of coronavirus transmission,” Politico’s Max Cohen reports. "She also declined to answer when asked which health experts the White House had consulted about conducting rallies this summer.” 

OOF: Scientists are still trying to understand why covid-19 can be a killer to some otherwise healthy people, while others are spared.

For some patients it means days or weeks on a ventilator, while others experience no symptoms at all. 

“Among their lines of inquiry: Are distinct strains of the coronavirus more dangerous? Does a patient’s blood type affect the severity of the illness? Do other genetic factors play a role? Are some people partially protected from covid-19 because they’ve had recent exposure to other coronaviruses?” Joel Achenbach, Karin Brulliard and Ariana Eunjung Cha report. 

Here’s what scientists do know: Covid-19 is more likely to be worse for people over the age of 60. It’s worse for people with chronicle health conditions, including diabetes, lung disease and heart disease.

Edward Behrens, chief of the rheumatology division at Children’s Hospital of Philadelphia, called the disease’s variability “the most critical question about covid.” 

National Institutes of Health Director Francis Collins highlighted one potential breakthrough on his blog, noting that scientists developed a tool to sort patients’ blood, finding 22 proteins that appeared repeatedly among severely ill patients. That kind of information could be useful, if blood tests and analysis are done early to determine what patients are most at risk of becoming very sick. 

There are also other new theories related to genetics, obesity and differences in immune system, they add. 

OUCH: There is no official tally of the number of health-care workers who have died of the coronavirus. 

The Centers for Disease Control and Prevention says more than 77,800 have tested positive and more than 400 have died. But the agency admits that’s is too low. 

The nation’s largest nurses union, National Nurses United, lists the number of health-care worker deaths at 939, based on information from its chapters, obituaries and social media. 

“And those may be just the first casualties, with new coronavirus cases surging in parts of the South and the Far West and the possibility of a second wave of the pandemic in the fall,” Ariana, Kent Babb and Brittany Shammas report. “Co-workers of those who’ve died have been left to deal not just with grief but a mix of anger, frustration and fear. Heath care, after all, is as much a calling as a job for many of them; during a pandemic, learning a colleague or relative is infected or worse means an almost daily reckoning — not just with one’s own mortality, but also with a growing sense of powerlessness.” 

You can read some of the wonderful stories remembering front-line workers who have died, including that of 60-year-old veteran nurse Daisy Doronila of New Jersey; 57-year-old Jeff Baumbach of California; 65-year-old Aleyamma “Molly” John of New York; and 53-year-old Kim King-Smith of New Jersey. 

The Trump administration's efforts

Trump is pressuring health officials to move even faster on an already ambitious timeline to develop a coronavirus vaccine. 

“The goal is to instill confidence among voters that the virus can be tamed and the economy fully reopened under Trump’s stewardship,” Yasmeen Abutaleb, Josh Dawsey, Laurie McGinley and Carolyn Y. Johnson report. “In a meeting last month with Health and Human Services Secretary Alex Azar — who is overseeing the effort called Operation Warp Speed, along with Defense Secretary Mark T. Esper — Trump pushed Azar repeatedly to speed up the already unprecedented timeline, according to two senior White House officials familiar with the meeting who spoke on the condition of anonymity to discuss private conversations.”

The president is hoping some people can get the vaccine before the end of the year. 

His push also coincides with his call for states to continue reopening even as some see a surge of new cases. 

Some scientists, as well as people close to the White House, “worry that his fixation on the timeline, combined with his past dismissal of scientists’ recommendations, could put regulators under intense pressure to approve some sort of limited use of a vaccine before it has been adequately vetted for safety and effectiveness,” they write. “Some go so far as to raise concerns about an “October surprise” in which the administration issues an emergency authorization for a vaccine right before the Nov. 3 election, regardless of whether the research justifies it.” 

In the states

Massachusetts is setting an example on how to do contact tracing.

The state, the first to create a statewide contact tracing system, organized the Community Tracing Collaborative led by its individual insurance marketplace and its public health department. The collaborative has hired more than 1,000 people working on contact tracing who are supporting more than 1,000 additional contact tracers working through the state's 351 boards of health.

The collaborative consistently has fewer than 50 confirmed cases and contacts that are awaiting outreach, according to Jason Lefferts, communications director for the Commonwealth Health Connector. It has made more than 318,000 calls to cases and contacts, he said.

“At this point, Massachusetts is able to keep up on contact tracing,” Lefferts wrote to The Health 202.

United States of Care, a nonpartisan group advocating for improved health care in the U.S., is releasing a handbook for state leaders as they consider a potential second wave.

The handbook, provided first to The Health 202, recommends steps states can take to avoid the drastic shutdown measures that were necessary over the spring.

“With smart preparation now, a subsequent wave of covid-19 does not need to look like the first few months, with widespread lockdowns and a scramble to build health system capacity, leaving people confused and worried that the health care system might not be there for them when they need it,” the guide says.

It recommends five key steps officials could take in preparing to deal with future spikes. They include: listening to the needs of different communities, using data to guide quick decision-making, focusing on protecting people most at risk, ramping up the capacity of health systems, and working with public and private stakeholders.

The guide also points to examples of states that have seen better results through data-driven and timely actions by public officials. Minnesota, for example, launched a five-point plan to protect residents of long-term care facilities — places that have been ravaged by the virus. Utah delayed its phased-in reopening in counties with higher levels of cases and risks, using a color-coded system to quantify their risk.

Face coverings may have saved people from the spread of the coronavirus inside a Missouri hair salon. 

A sick hair stylist worked eight shifts over nine days at a Great Clips, despite showing symptoms. Another stylist from the same Great Clips also tested positive. At least 140 people had close contact with the pair of stylists, and hundreds more had been inside the salon. But local health officials had required face masks at personal care shops, including at salons and barber shops. Customers were required to wear a mask to enter the Great Clips, too. Both of the stylists wore cloth masks, Todd C. Frankel reports.

The stylists’ customers and colleagues were offered free testing, but just 46 out of 140 customers were tested. 

“Fourteen days after the second hair stylist tested positive, Goddard announced that there appeared to be no new infections from the Great Clips exposures,” Todd reports. “There had been a slight uptick in cases after Memorial Day, but they did not appear to be connected to the hair salon.” 

Todd writes: “The result appears to be one of the clearest real-world examples of the ability of masks to slow the spread of the novel coronavirus. It also highlights the challenges for public health officials around the world who at times have sounded ambivalent about masks as they are still trying to understand the threat from this new virus.” 

Coronavirus fallout

There could be half a million fewer births next year as a result of the pandemic-driven recession.

Economists writing for the Brookings Institution estimate in a new report that there could be “on the order of 300,000 to 500,000 fewer births next year” in the United States. 

“The economists, Melissa S. Kearney and Phillip Levine, derive their estimates from data on birthrates during the Great Recession and the 1918 flu pandemic. Both of those upheavals had a considerable negative impact on fertility,” Christopher Ingraham reports. “… The reason? Children are expensive, and having a child is in many ways a financial decision. The loss of a job or otherwise uncertain prospects for a steady income lead many would-be parents to postpone having kids until things are more settled.” 

He also notes that the 1918 pandemic had a permanent impact on American families. Many had fewer children overall, rather than having more kids later to make up for any previous decline. 

The opioid crisis continues

There’s still an opioid epidemic taking its toll on the nation. 

In an op-ed in Morning Consult, Patrice Harris, who recently completed her term as president of the American Medical Association, describes reports of surges in opioid-related deaths, mental health crises, suicides and addiction-related relapses in more than 30 states. 

“Social distancing, a dramatic increase in unemployment and widespread economic woes lend themselves to common substance misuse triggers: isolation and anxiety,” she writes. “The medical community often refers to addiction as ‘a disease of isolation,’ and Americans are at high risk now, even those who did not misuse opioids previously. Those who are homeless or incarcerated may be particularly vulnerable.” 

Coronavirus latest

Here are a few more stories to catch up on this morning: 

The Trump administration’s efforts: 
  • The Food and Drug Administration sent three companies warning letters for allegedly marketing unauthorized at-home test kits to consumers and for falsely claiming that products were “FDA approved,” Marisa Iati reports for The Post’s live blog.
The latest update on hydroxychloroquine: 
  • The World Health Organization said it stopped the use of the anti-malaria drug hydroxychloroquine in its multicountry study after finding it did not appear to benefit covid-19 patients or result in the reduction of mortality, Miriam Berger writes for The Post’s live blog.
More from the states:
  • Oregon Gov. Kate Brown (D) said people in seven counties will be required to wear face coverings while in indoor public spaces as virus cases there soar.
  • Arizona Gov. Doug Ducey (R) gave local authorities permission to require face coverings in public, as infections continue to surge in the state.
What is happening after states reopen: 
  • Restaurants across the country that were given the green light to reopen their doors have had to close again after workers have tested positive for the coronavirus, Emily Heil reports.

Sugar rush

The USDA considers the Navajo Nation a "food desert" with scant access to healthy food on the reservation. So many Navajo have returned to growing their own. (Video: The Washington Post)