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Ann Thorac Surg 2003;76:S1348-S1355
© 2003 The Society of Thoracic Surgeons
a Division of Cardiothoracic SurgeryLos Angeles, CA, USA
b Research Centers in Minority Institutions, Charles R. Drew University of Medicine and Science, Los Angeles, California, USA
* Address reprint requests to Dr Scott, Charles R. Drew University of Medicine and Science, 12021 S. Wilmington Avenue, Los Angeles, CA 90059, USA
e-mail: roscott{at}cdrewu.edu
Presented at the symposium on Understanding Disparities in Cardiovascular and Thoracic Surgical Outcomes in African Americans, San Diego, CA, Jan 30, 2003.
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Introduction |
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 Top Introduction Slave medicineThe origins of anginaModern therapies for coronary...The meharry cohort studyThe unexplained differencesOpportunities for african...An historic legacyAcknowledgmentsReferences |
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Although socioeconomic status has been posited as a major contributor to these observed differences [2], there is strong evidence that racial/ethnic health disparities persist at every socioeconomic level. Williams proposes that these differences reflect the impact of the social environment and the cumulation of adversity across multiple domains. These differences in health and their persistence through time reflect, in large part, policies and practices that are linked to the historic legacy of racism and that have created living conditions that are pathogenic for non-White populations [1]. The Institute of Medicine's landmark report from the Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care adds additional evidence. The Committee found that "disparities are consistent and extensive across a range of medical conditions... and occur independently of insurance status, income, and education, among other factors that influence access to healthcare" [3]. To help elucidate how the current policies and practices have evolved, this article will review the historic treatment of African-American patients and healthcare providers, both in general and as specifically related to cardiac disease. Even though, one may argue, it is unintentional, a subtle form of racial bias persists among medical providers and, to variable extents, impacts the cardiac as well as overall health of African Americans.
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Slave medicine |
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TopIntroductionSlave medicineThe origins of anginaModern therapies for coronary...The meharry cohort studyThe unexplained differencesOpportunities for african...An historic legacyAcknowledgmentsReferences |
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The extent to which investments in plantation health facilities benefited slaves is difficult to ascertain for a variety of reasons. It was not until 1850 that the Bureau of the Census began collecting mortality data by disease and race/ethnicity, and then only in a limited number of states. Further, most authorities believe that the data collected on African-Americans are generally less accurate than those on Whites. However, descriptive accounts suggest that the elevated mortality rates of slaves from this period were associated with the terrible living conditions of most slave quarters and diseases such as dysentery, cholera, pneumonia, and tuberculosis [6]. Comparative data from the state of Virginia in 1850 indicate that "suffocation" and homicide were unique to slaves as causes of death [7].
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The origins of angina |
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TopIntroductionSlave medicineThe origins of anginaModern therapies for coronary...The meharry cohort studyThe unexplained differencesOpportunities for african...An historic legacyAcknowledgmentsReferences |
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In his 1931 address to the annual meeting of the American Heart Association, Roberts of Emory University Hospital differentiated angina pain from the pain of coronary thrombosis, acute aortitis, syphilis or rheumatic fever, or organic heart disease. Roberts regarded angina as a paroxysmal thoracic complaint modulated by nervous and mental influences, occurring without any electrocardiogram changes and usually in the "sensitive, nervous type, as the Jew, or in the tense, efficient American." He characterized angina as increasing in society as civilization advanced and human (the White human) was burdened with living in urban conditions of competition, work, and strain. According to Roberts, angina did not occur in the humorous, careless, musical black or the placid, accepting Chinaman [8].
Roberts' treatise was consistent with those of other writers of the day regarding the rarity, if not the nonexistence, of angina in African Americans [12–17]. He asserted that African Americans have a less acute perception of pain because they "seem to be less highly organized nervously" [8]. Schwab and Schulze [17] also believed that the observed differences were due to an inherent difference in the sensitivity of the respective nervous systems and that there was a "profound dissimilarity in the psyche and sensorium of the two races."
Also attributed to the African American was difficulty in providing an accurate history. In 1928, Davison and Thoroughman [15] described the African-American patient as an individual "who complains very little and who notices his symptoms very little, unless they are of sufficient degree to cause complete or partial disability." The predominant belief in addition to the underdeveloped nervous system of the African American was the belief that their cardiovascular systems were also defective. Some believed that there was an inherited defect that contributed to the early breakdown from infection, degeneration, toxemia, or the stress and strain of the complexities of modern civilization [18].
A review of approximately 20,000 African-American inpatients treated at Emory over a 9-year period in the 1920s revealed only five diagnoses of angina. On further examination of the records, Roberts suggested that the correct diagnoses for these 5 patients were coronary thrombosis, acute fibrinous pleurisy, precordial distress from congestive heart failure, and "apical distress from religious and musical fervor" [8]. Toward the end of the 1930s, there was some mitigation of the attitude that African Americans could not experience the pain of angina. Ostensible racial differences in angina were increasingly explained by the notion that African Americans were not sufficiently intelligent to describe pain. Poor Whites were now included in this discussion. Weiss [19] compared the incidence of angina among 246 White and 324 African-American charity patients with hypertension treated at Louisville City Hospital. A history of angina was obtained from 4.8% of the White patients and 2.8% of the African-American patients [19]. Weiss cited several of his contemporaries who also commented on the comparative infrequency with which angina was encountered in charity patients. Czyhlarz [20] echoed Roberts' thoughts in attributing the infrequency to a difference in the sensitivity of the nervous system. Hamman [21] believed that angina would always be a disease of the refined, intellectual classes, because its effects are keenly appreciated and fluently described by the alert, but not by the intellectually obtuse.
Autopsy studies at Louisville confirmed that both White and African American hypertensive patients had severe coronary sclerosis and myocardial infarction. African American women had the highest incidence of coronary disease: 31% compared with 20% in African American men, 21% in White men, and 24% White women. Similar rates of infarction were found in all subsets. Although Weiss was willing to accept the fact that African Americans were susceptible to pain, he attributed the difference in angina between charity patients (both African American and White) and White private patients to the requirement of a "more than moronic intelligence" to describe the attack [19].
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Modern therapies for coronary artery disease |
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TopIntroductionSlave medicineThe origins of anginaModern therapies for coronary...The meharry cohort studyThe unexplained differencesOpportunities for african...An historic legacyAcknowledgmentsReferences |
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As late as 1985, at a conference on heart disease in Baltimore, the first author presented a study on the surgical management of coronary artery disease. She was told by an African-American physician during the question and answer period, "I have been practicing cardiology for almost 50 years, and I have never seen a black with angina or coronary artery disease!" This physician's experience was likely a reflection of what he had been taught to diagnose, rather than a lack of diagnostic skill.
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The meharry cohort study |
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TopIntroductionSlave medicineThe origins of anginaModern therapies for coronary...The meharry cohort studyThe unexplained differencesOpportunities for african...An historic legacyAcknowledgmentsReferences |
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In 1988, Meharry Medical College began to pool the cohort study data with a similar study of White medical students at the Johns Hopkins University. Accordingly, 435 African-American medical students from the 1958 to 1965 classes of Meharry and 580 White medical students from the 1957 to 1964 classes of Hopkins have been followed for more than 30 years. Data were obtained at 22.5 years old, 25 to 30 years old, and at 35 years old. At follow-up, the African-American study participants had a 40% greater incidence of coronary artery disease and an alarmingly higher case fatality rate (51.5% vs 9.4%). The strongest predictors of cardiovascular events were cigarette smoking, cholesterol, and parental history in White physicians and blood pressure in African-American physicians. Although all African-American males are disproportionately affected by hypertension, the prevalence rate was greater among African-American physicians than the African-American male population at large (40% vs 30%). After adjustment for age, body-mass index, systolic blood pressure, and cigarette smoking, the continued higher risk of hypertension in the African-American physicians could not be explained by differences in perceived stress or socioeconomic status. The Meharry-Hopkins Cohort investigators concluded that education and affluence provided the Meharry cohort with little protection, and that the excess risk of hypertension in African American men persists even when disparities in the main determinants of socioeconomic status are minimized [23].
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The unexplained differences |
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TopIntroductionSlave medicineThe origins of anginaModern therapies for coronary...The meharry cohort studyThe unexplained differencesOpportunities for african...An historic legacyAcknowledgmentsReferences |
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In 1980, the National Black Health Providers Task Force in High Blood Pressure Education (which was convened by the National Heart, Lung and Blood Institute [NHLBI] in 1977) recommended that increased attention be directed towards targeted research in cardiovascular disease in minorities. The task force was particularly interested in studies of the biological, behavioral, and environmental factors that might explain the observed differences in disease rates between population groups [25].
The NHLBI Working Conference on Coronary Heart Disease in Black Populations was one of NHLBI's first responses to these needs. The Working Conference, held in September 1983, brought together a multidisciplinary group of research scientists and community health experts with relevant concerns or research experience.
The presentations and workshops [26–29] at the conference emphasized the lack of data on the prevalence and implications of coronary heart disease in African Americans. Probably the task force's most significant contribution was highlighting the marked discrepancies and gaps in knowledge about coronary heart disease in African Americans. The conference proceedings have guided subsequent targeted research initiatives.
At that meeting, the first author presented outcome data on African-American men who underwent myocardial revascularization at Walter Reed Army Medical Center, which at the time had been conducting bypass surgery for 13 years. Between 1970 and 1983, 1541 patients underwent surgery. The 54 African-American men (3.5%) had early outcomes that were comparable to the other patients treated at Walter Reed. Overall operative mortality for the African-American soldiers was 5.6%. After the implementation of cardioplegia in 1978, the mortality rate decreased to 2.5%. These data are compared with 4.2% and 3.6%, respectively, for the patients who were not African American [30].
Watkins and colleagues [31] reported on the Johns Hopkins experience during the same time frame. Their study of urban African Americans who underwent coronary artery bypass graft (CABG) procedures at the Johns Hopkins Hospital between 1972 and 1980 revealed higher rates of mortality, unstable angina, and diffusely diseased arteries among the African-American patients than the White patients. The 56 African Americans in the study had an overall mortality rate of 9%. Those African Americans who presented with unstable angina had a 14.8% mortality rate, almost three times that of the general population of patients. The most striking finding in the Hopkins series was the advanced state of disease by both clinical presentation and catheterization. Fifty percent of the patients had progressed to unstable angina by the time of surgery. Anatomically, the majority of patients were found to have severe and diffuse atherosclerotic disease [31].
These contrasting results raise the question, if being African American in U.S. society affects health, do the career soldiers treated at Walter Reed Army Medical Center represent an important subset of African Americans who live and work in a more egalitarian environment, an environment in which they are receiving appropriate care, being judged by the content of their individual characters and not being prejudged by society's assumptions about their collective character? [32]
Unfortunately, African-American veterans and the general population may not be the beneficiaries of similar treatment. Whittle and colleagues [33] examined the use of cardiovascular procedures among 882,930 African- American and White male veterans discharged from Veterans Affairs hospitals with primary diagnoses of cardiovascular disease or chest pain from 1987 through 1991. They found that White race was a strong predictor of the use of coronary angiography, angioplasty, and bypass surgery regardless of primary diagnosis, race, age, coexisting morbidity, year of index hospitalization, marital status, region, and whether the index hospitalization was in a CABG center. The odds ratio for receiving a cardiovascular procedure for a White as compared with an African-American veteran was highest for bypass surgery, at 2.2 [33].
Studies of racial/ethnic variation in the use of coronary revascularization have reported similar results. More than 12,402 patients with documented coronary artery disease on catheterization between 1984 and 1992 were analyzed at Duke University Medical Center. African Americans were 13% less likely than were Whites to undergo angioplasty and 32% less likely to undergo bypass surgery. Among patients with severe coronary artery disease, 48% of the African-American patients and 65% of the White patients (p < 0.001) underwent bypass surgery. For patients expected to survive for 2 months or less after surgery, African Americans were only slightly less likely than Whites to undergo surgery (8% vs 10%, p = 0.46). For those expected to survive more than 1 year, 42% of the African-American patients underwent surgery compared with 61% of the White patients (p < 0.001) [34].
Hannan and colleagues [35] sampled hospitals in New York State to determine if there were racial differences in access to surgery among patients determined appropriate for surgery. They studied 1261 patients in eight hospitals. After controlling for age, payer, number of diseased vessels, and presence of left main disease, both African-American and Hispanic patients were less likely than Whites to have bypass surgery. The respective odds ratios were 0.64 and 0.60. The investigators noted that both race/ethnicity and payer status proved to be significantly related to utilization of bypass surgery in statistical models where payer status was represented separately. The odds ratio for minorities undergoing surgery would have been substantially lower if adjustments had not been made for payer status. As part of this study, a random sample of gatekeeper physicians were interviewed. If they recommended surgery, 90% of patients would undergo a procedure. This percentage was not affected by patient race/ethnicity or gender. The investigators concluded that African-American patients had significant access problems in obtaining bypass surgery and that these problems appeared not to be related to patient refusals [35].
Beyond the racial/ethnic variation in use of bypass surgery, differences have also been found in the actual conduct of the operation. In the recent bypass angioplasty revascularization investigation (BARI), being African-American was an independent risk factor for not receiving an internal mammary artery and for higher mortality. Unfortunately, being African American remained a predictor of death even after adjusting for internal mammary use [36].
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Opportunities for african-american physicians |
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TopIntroductionSlave medicineThe origins of anginaModern therapies for coronary...The meharry cohort studyThe unexplained differencesOpportunities for african...An historic legacyAcknowledgmentsReferences |
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Among the proposed solutions to health disparities is to increase the number of African-American healthcare providers. Physician-patient race concordance may be expected to lead to better quality care for African Americans as well as greater patient satisfaction [40]. There is some evidence that this may be the case in cardiac surgery. In contrast to the findings of the VA study discussed above, Dr. Reginald Peniston, an African- American thoracic surgeon, reported that patients at Washington, DC's VA Medical Center did not differ in treatment received by race/ethnicity. He and his colleagues found that between 1986 and 1992, there were no racial/ethnic differences in the likelihood of having angioplasty or bypass surgery or short-term mortality among the 1460 veterans studied. Decreased survival beyond 3 years after cardiac catheterization was negatively impacted in their multivariate analysis by African- American ethnicity, advancing age, ventricular function, and clinically significant congestive heart failure. Survival was positively affected by bypass surgery but not by angioplasty. Peniston and colleagues [41] comment that the decreased life expectancy of African-American veterans is very likely "reflective of a frequently cited, society-wide phenomenon and its poorly defined and confusing explanatory variables." They recognize that their study did not include data to analyze conclusively the reasons behind higher long-term mortality among African-American patients [41].
Disparities extend beyond the treatment of patients to the opportunities and professional support offered to physicians and other clinicians. The American Medical Association (AMA) was formed in 1846 in New York City with its main purpose to standardize the requirements for conferring medical degrees. The association's early code of ethics established definitional boundaries around the medical profession by denying membership to "irregulars" such as herbalists, chiropractors, and practitioners of homeopathy. Exclusion criteria for membership, however, were not based solely on clinical practice or philosophy, as many AMA-affiliated local medical societies also explicitly denied membership to African Americans [5].
Doctor Miles Vandahurst Lynk, an African-American physician from Memphis, Tennessee, had urged the establishment of a national organization of African- American physicians in an 1892 editorial in the Medical and Surgical Observer, a periodical he founded that was the first African-American medical journal.
In October 1895, during Atlanta's Cotton States and International Exposition, the African-American physicians who could be located in attendance were invited to meet at the First Congregational Church for the purpose of establishing a national organization of practitioners of medicine, surgery, pharmacy, and dentistry (Fig 1). The 12 physicians present agreed unanimously on the need for such an organization and the National Medical Association (NMA) was born. Doctor Robert Fulton Boyd was chosen as the first president and Dr. Daniel Hale Williams was the first vice president [42, 43].
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Conceived in no spirit of racial exclusiveness, fostering no ethnic antagonism, but born of the exigencies of the American environment, the National Medical Association had bonded together, for mutual cooperation and helpfulness, the men and women of African descent legally engaged in the practice of medicine, surgery, pharmacy, and dentistry. [46]
The NMA was founded in the midst of the decline of Reconstruction in the South as racial tensions were growing. Segregation was being enacted into law all over the South and African Americans were being disenfranchised. Discrimination and inequity in education were accepted as morally right. African-American students were denied admission to the vast majority of medical schools, and African-American patients were rigidly segregated in hospitals and clinics. Few hospitals anywhere in the country granted privileges to African-American physicians [47]. In some instances, White nurses were even prohibited from caring for African-American patients.
Continuing organizational policies that were discriminatory in both intent and effect contributed to a severe shortage of physicians who were willing to care for African Americans. By 1930, African Americans living in Mississippi had only one doctor for every 14,634 persons [48]. Conditions in the North were only slightly better. As late as 1912, only 19 of New York City's 29 hospitals would admit African-American patients; only three would give African-American physicians the right to attend their patients or perform operations [49].
The policies of the nation at the time the NMA was founded resulted in a de facto dual health care system. The priority item on the first NMA agenda and the one that continues to remain on the agenda is how to eliminate disparities in health and attain professional medical care for all people. Despite the sustained efforts of African-American physicians and the NMA to open up the AMA, it was not until 1966 (120 years after its founding) that the AMA amended its bylaws. The bylaws were amended to allow a physician denied membership to state or local medical societies on racial grounds to appeal that decision to the AMA [5].
Doctor Daniel Hale Williams' participation in the founding of the NMA is just one of the many major accomplishments of this extraordinary physician (Fig 3). Born before the Civil War, he became a virtual orphan as a child due to the early death of his father. Doctor Williams' mother was forced to take him out of school and apprentice him as a shoemaker. Thereafter he was only able to attend school sporadically but, despite all of the tremendous challenges he faced, Dr. Williams eventually became the first African American to graduate from Northwestern University Medical School (formerly Chicago Medical School).
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In 1890, Reverend Louis Reynolds approached Dr. Williams for help after his sister Emma was refused admission to nursing schools because she was African American. This led to the founding of the Provident Hospital and Nursing Training School (Fig 4) in 1891. The first years of the hospital were challenging but successful. Doctor Williams established competency requirements for the hospital's physicians and insisted that they remain abreast of emerging medical discoveries. The staff was open to both White and African-American physicians. The hospital prospered and by 1896 the need for a new larger building became apparent.
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With no real surgical precedent to follow, Dr. Williams watched his patient slowly fade and finally made the decision to attempt surgery. The patient had a lacerated internal mammary artery, pericardial wound, and a small injury to the heart muscle that was not bleeding. He repaired the pericardium with a continuous suture of fine catgut [50]. By demonstrating that a surgical approach to cardiac wounds was technically feasible, his approach represented the foundation upon which modern heart surgery is based. He performed at least two additional operations on stab wounds to the heart later in his career. His contributions to our field continued with the publication of his experience with penetrating wounds of the chest that perforated the diaphragm and involved the intraabdominal viscera [51].
In 1920 the first author's uncle, Dr. Arthur G. Falls (Fig 5), also enrolled in Northwestern Medical School. In an interview years later he remembered being largely ignored by his classmates. He also had to endure the derisive remarks of his professors. "If you're not sure what to do," they told their students, "go find a nigger and use him as a guinea pig" [52]. With such bias so openly expressed in medical schools, it is no wonder that the Tuskegee Syphilis study, which lasted from 1932 to 1972, was carried out with such lack of concern for its participants. The study was well known in scientific circles and was the subject of at least 12 published reports before it was closed. The most tragic phase of this clinical trial occurred after the introduction of penicillin in 1943. In spite of the fact that the local health department used penicillin routinely, the men in the trial were not given the medication nor told that a cure for syphilis was available [38].
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An historic legacy |
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TopIntroductionSlave medicineThe origins of anginaModern therapies for coronary...The meharry cohort studyThe unexplained differencesOpportunities for african...An historic legacyAcknowledgmentsReferences |
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Discrimination against African Americans extended to medical education, which severely impeded the development of an adequately diverse profession. One of the most regrettable aspects of this history is the involvement of health policymakers at the federal level. Between 1946 and 1962, grants totaling approximately $37 million were awarded to racially segregated medical facilities through the so-called "separate but equal" provision of the 1946 Hill-Burton Act. As the first significant piece of health planning legislation in the U.S., Hill-Burton instituted structural and procedural barriers to care for African Americans from which we have still not recovered. Title VI of the 1964 Civil Rights Act would eventually prohibit the granting of federal funds to racially segregated health care facilities, but the long-term monitoring of providers necessary for enforcing this legislation has proven difficult to implement [5]. Consequently, much of the promise of the civil rights movement in terms of equity in health status and access to services has not been fulfilled. In this regard, research can provide crucial data to inform policy and practice that will continue to refine efforts to improve the health of all Americans.
Doctor James Jones, in a recent editorial in this journal, eloquently presented his case for a lack of evidence that thoracic surgeons systematically or intentionally deny operations to minority patients [54]. Unfortunately, bias may often be subtle. In addition, Dr. Jones may have underestimated our influence on our colleagues and on our communities. As leaders of our profession, as well as valued and respected members of society in general, what responsibility do we bear in the discussion of health disparities and professional opportunities? We would argue that the thoracic surgery community must join our entire profession in considering the extent to which we have truly overcome the legacy of racism and have ensured that all members of our society are benefiting equally from the full spectrum of our achievements.
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Acknowledgments |
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TopIntroductionSlave medicineThe origins of anginaModern therapies for coronary...The meharry cohort studyThe unexplained differencesOpportunities for african...An historic legacyAcknowledgmentsReferences |
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References |
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TopIntroductionSlave medicineThe origins of anginaModern therapies for coronary...The meharry cohort studyThe unexplained differencesOpportunities for african...An historic legacyAcknowledgmentsReferences |
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