April is national Minority Health Month, so we’ve turned to our man in the trenches, Wil, for some insight into what it’s like helping minority populations with their diabetes:
By D’Mine Columnist / Correspondent Wil Dubois
If your skin is darker than mine, I’ll likely live longer than you will. And better, too — at least health-wise. Sucks, I know, but it’s true. But why is it so? Why aren’t the needs of America’s minority persons with diabetes (PWDs) being met? Amy asked me to report my observations from healthcare’s frontlines. To tell you what I see as the greatest needs of the minorities I work with, where we’re succeeding and failing as a nation, and what our best hope for a more equal future might be.
But first, just who is a minority, anyway? And what does it mean to your health to be a “minority?”
Actually, I’m a minority. What? Couldn’t you tell by looking at me? No, you don’t need glasses. I’m a White guy, but where I live and work, 77 percent of the population is Hispanic, so around here I’m a true minority.
But when any agency of the federal government rolls out the M-word, you can be pretty sure they’re talking about people with beautiful skin: black, brown, red, or yellow. The Centers for Disease Control and Prevention, sponsors of Minority Health Month, officially define a minority as an: American Indian or Alaska Native, Asian American, Black or African American, Hispanic or Latino, and Native Hawaiian or Other Pacific Islander.
About a third of the population of our country belongs to one of these groups; and while the exact statistics vary with the exact shade of your skin—minorities universally suffer worse health outcomes than Whites in our country. You can read all the depressing details here, but in a nutshell, minorities have higher age-adjusted death rates from heart disease, cancer, stroke, HIV/AIDS, and yes: diabetes, too. If you’re Hispanic, for instance, you’re 1.5 times more likely to die from diabetes complications than if you’re White.
The official moniker for this social disgrace? Health disparities.
My two roles in healthcare
OK, so where do I come into play in all of this? Very briefly, when I’m not writing, I have two “day jobs,” both involving working with different minority groups. I head the diabetes education program as an un-certified diabetes educator at a rural non-profit clinic that mainly serves Hispanics; and I also work for a University of New Mexico School of Medicine-run program that’s trying to foster a whole lot more people like me, mainly among the State’s Native American population.
So I have a front row seat when it comes to “health disparities.”
How we’re meeting the needs of minority PWDs in my state
Here in New Mexico we have a number of creative ways to hook patients up with the resources they need. Some have private insurance (although nationwide 42 percent of Hispanics have private insurance compared to 76 percent of Whites); many have Medicaid; and quite a few are uninsured altogether. Fully a quarter of my patients live under the federal poverty level, which is a paltry $930 a month for a single person. So even if they’re insured, after paying for light, heat, food, and gasoline—many have nothing left in their pockets. They can’t even afford generic drugs at Wal-Mart.
Here’s my playbook for this mess. For the uninsured, I can almost always get Big Pharma to step in and actually give anyone who makes even up to double or triple the poverty level free drugs. For the under-insured (welcome to hell) I find that co-pay cards, also from Pharma, are a huge help. These are credit card-like vouchers that can lower upper-tier copays for meds down to a more affordable amount. As a federally qualified non-profit clinic, we can also get many drugs at Veteran’s Administration pricing, sometimes pennies on the dollar.
And you won’t believe this, but I have Big Tobacco to thank for the improved health of my patients (well, at least the ones that didn’t die of emphysema and lung cancer); part of our state’s tobacco settlement funds are used to purchase blood glucose meters and strips for clinics like mine to give to needy patients. On top of that, our Attorney General was part of an anti-trust lawsuit against a number of the large mail-order suppliers of diabetes meds who were accused of price fixing. Funds from that settlement let us to sell test strips to our patients for only $3 per vial of 50.
A mix of government and private grants have helped us with vision screenings, lab co-pays, and educational materials.
Health insurance access is only part of the solution — barriers are the real ball-breakers
The truly poor in America generally qualify for Medicaid, and in fact, minorities disproportionally receive Medicaid. African Americans, who make up about 13 percent of the population, make up 22 percent of the Medicaid recipients; and Hispanics, at 16 percent of the country’s population, are fully 28 percent of the Medicaid recipients. And I gotta tell you, from where I sit, Medicaid actually gives a hell of a lot better coverage than many of the private health insurance plans do.
So on the surface, poor and brown seems to have better access to medical care than working and White — but we’re missing something, as the long-term health outcomes of minorities in America are still much worse than they are for their White counterparts. Why?
Because even with coverage for care, in general, minorities don’t seem to get that care. What’s up with that? Well, some of the identified barriers include poverty and all that comes with it: lack of education, limited literacy levels, transportation problems, substance abuse, toxic housing, “grocery deserts” where there is no access to healthy foods, and inter-family violence.
Language and culture barriers also come into play with minority populations, for instance many Native peoples avoid “White Medicine,” and African Americans have good historical reasons for avoiding trips to the hospital. In Hispanic communities, intergenerational historic trauma comes into play as well, with poor health outcomes from previous generations leading to complete fatalism about the effectiveness of diabetes care.
But from what I see in the trenches, the biggest single barrier is a form of unintended prejudice. Minorities have difficulty with “doc” talk and doc attitudes, both of which are all too commonly adopted by Certified Diabetes Educators (CDEs) as well.
Simply put: docs and CDEs understand diabetes and medicine, but they don’t understand the people they serve. They don’t get the culture, the language, or the mindset of their patients. While docs often fume that patients are “non-compliant,” the patient leaves the clinic wondering what the hell the doc just told them to do, or feeling discouraged that the doc has asked them to do something impossible, given the patient’s circumstances. This is true even for doctors who originally came from minority communities themselves; by the time they graduate medical school, they’ve often lost their ability to communicate with the people they once had so much in common with.
Is the Promotora the cure?
Proma-who? That’s a Spanish word, short for Promotora de la Salud — a promoter of health. A Promotora is a member of the community who gets a small amount of specialized medical training, enough to understand and communicate with doctors, and then serves as a liaison and translator between the patient and the provider. Because Promotoras come from the communities they serve, they already “get” the culture, language, and mindset of the locals. They’re called Community Health Representatives in Native Communities, and Community Health Workers in other parts of the country.
In most parts of the world, they’re valued members of the medical team. Here in the U.S. the feds have recently woken up to their value, which has been extensively researched, especially in the arena of diabetes.
Wonderful, you say, we have a solution! Ummmm….. No. There’s a problem. And the problem is the docs and CDEs themselves, many of whom don’t like to play in the sandbox with people who don’t have a lot of alphabet soup behind their names.
Despite all the evidence for the effectiveness of this model, American medical professionals have been stubbornly resistant to embracing it. It treads on toes, after all. It’s a model that forces collaboration, recognizes that there’s knowledge and wisdom that doesn’t come from advanced degrees, and requires docs to admit that they don’t know everything.
Rather than viewing this specialized community ambassador as a logical and valuable extension of the medical team, too many medical professionals view them as an uncouth threat to the natural order — the way things have always done. (Editor’s Ref: the Amanda Trujillo case — and she was a trained nurse!)
So the first step on the long road to eliminating Health Disparities in our country, i.e. to making the color of our skins irrelevant to our health outcomes, is to change the culture of American medicine.
And that’s going to be a tough pill for many people in medicine to swallow.
Thanks, Wil, for your ever-raw honesty on tough topics!