AMERICAN JOURNAL OF ~~~ _ aS
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June 1977 Volume 67, Number 6
Established 1911
Black Physicians and Black Communities EDITOR Alfred Yankauer, MD, MPH EDITORIAL BOARD
Michel A. Ibrahim, MD, PhD (1977)
Chairperson Rashi Fein, PhD (1978) Ruth B. Galanter, MCP (1977) H. Jack Geiger, MD, MSciHyg (1978) George E. Hardy, Jr., MD, MPH (1978) C. C. Johnson, Jr., MSCE (1977) Geroge M. Owen, MD (1979) Doris Roberts, PhD, MPH (1977) Pauline 0. Roberts, MD, MPH (1979) Ruth Roemer, JD (1978) Sam Shapiro (1979) Robert Sigmond (1979) Jeannette J. Simmons, MPH, DSc (1978) David H. Wegman, MD, MSOH (1979) Robert J. Weiss, MD (1977) STAFF
William H. McBeath, MD, MPH Executive DirectorlManaging Editor Allen J. Seeber Director of Publications Doyne Bailey Assistant Managing Editor Deborah Watkins Production Editor Janice Coleman Administrative Assistant CONTRIBUTING EDITORS George Rosen, MD, PhD Public Health: Then and Now William J. Curran, JD, SMHyg Public Health and the Law Jean Conelley Book Section
AJPH June, 1977, Vol. 67, No. 6
Dr. Lois Gray's article The Geographic and Functional Distribution of Black Physicians: Some Research and Policy Considerations which appears in this issue of the Journal' serves to underscore the lack of data on the distribution of black physicians in the United States. Aggregate data show a reasonably close match between the percentage of all physicians and the percentage of the population residing in four geographic regions of the country. However, these data indicate that the percentage of black physicians approximates the percentage of the population which is black in only one (North Central) region. Black physicians are more heavily concentrated in urbanized areas (92 per cent) than all physicians. This concentration is most marked in central cities (72 per cent) than in the urban fringe (20 per cent). Comparable figures for all physicians are 40 per cent and 36 per cent.' Less is known of the factors that influence the practice location decisions of black physicians. There is evidence to suggest that the racial characteristics of a community are less strongly correlated with the distribution of all physicians than are such factors as availability of hospitals and office space, and the average income of the population.2 It seems unlikely that black physicians would respond differently to these determinants of practice location. The existing concentration of black physicians may be a reflection of choice and continuing patterns of residential segregation, particularly in the North Central region of the United States. One would expect that if opportunities continue to improve for blacks to gain admission to medical schools and to prepare for the specialties of their choice, the distribution of black physicians will not be essentially different from that of all physicians. Does this mean that blacks will have even less access to black physicians? Probably not, given improvement in family income and access to good transportation. If black physicians do become less accessible to black communities, does it follow that the health of black communities will suffer? The answer to this question is less certain. It is well known that basic health indices show substantial deficits in the health status of blacks as compared with the rest of the population. However, health status indices such as infant mortality and life expectancy at birth are more strongly correlated with education and income than medical care. Most of the data used to construct health indices are not controlled for education or income. When income is taken into consideration, the differences between black and white indices are reduced but they do not disappear.3 When the percentages of the U.S. population never having received medically administered or prescribed preventive services are compared, the "black or other" category exhibits higher scores in six of seven services listed. However, the scores for black and other are lower than the scores for individuals with family income under $3,000 per annum for four of the seven services.5 While such comparisons must be interpreted with caution, it appears that both poverty and minority group status affect the utilization of preventive and other health services and that poverty is more important than race or ethnicity. The effect of poverty notwithstanding, in some areas of the United States there is still evidence of overt racial discrimination against blacks seeking medical care, and indications that blacks receive less thorough medical examina511
EDITORIALS
tions and that black women are more likely to undergo surgical procedures that result in sterilization.5 Given that the health indices of the black population are less favorable than those of the rest of the population and that this state of affairs cannot be explained wholly as an outcome of poverty, it should not be assumed that the answer lies in improving the access of the black population to black physicians. It is more likely that medically underserved populations, black or white, will benefit less from policies aimed at correcting physician maldistribution than they will benefit from policies designed (a) to ensure that the preferences of consumers are respected, (b) to eliminate finacial barriers to access to medical care, and (c) to increase the effectiveness and efficiency of the care provided. The health of all communities will improve as the environment is protected and the quality of individual and family life enhanced. The collection of health manpower data by race should be justified only as a means of monitoring equality of access to education for health careers. As Dr. Gray points out, inequalities in health services for black or white people, in rural or urban areas, are not the problem of black physicians; like
other inequalities in our society, they are the problem of us all.
ALONZO S. YERBY, MD, MPH
Address reprint tequests to Dr. Alonzo S. Yerby, Professor of Health Services Administration, Harvard School of Public Health, 677 Huntington Avenue, Boston, MA 02115.
REFERENCES 1. Gray, L. The geographic and functional distribution of black physicians: some research and policy considerations. Am. J. Public Health, 67:519-526, 1977. 2. Elesh, D. and Schollaert, P. T. Race and urban medicine: factors affecting the distribution of physicians in Chicago. J. Health and Social Behavior, Vol. 13, September, 1972. 3. Yerby, A. S. The Disadvantaged and Health Care. Am. J. Public Health, 56:5-9, 1966. 4. Selected Vital and Health Statistics in Poverty and Nonpoverty Areas of 19 Large Cities, United States, 1969-71, Vital and Health Statistics Series 21, No. 26. DHEW Publication No. (HRA) 761904. 5. Davis, K. and Marshall, R. Primary Health Care Services for Medically Underserved Populations. Papers of the National Health Guidelines: The Priorities of Section 1502. DHEW Publication No. (HRA) 77-641.
Pre-hospital Coronary Care The two reports by Pozen, et al." 2 in this issue of the Journal describe the implementation and early results of a telemetry ambulance system designed to improve pre-hospital care of patients with acute ischemic heart disease in southeast Baltimore county. The results of their efforts are of obvious import. The vast majority of acute cardiac ischemic events occur outside the hospital as do the majority of sudden deaths due to ischemic heart disease. For these reasons, programs aimed at improving the pre-hospital phase of the treatment of ischemic heart disease are of vital importance. The essence of the pre-hospital phase of coronary care is to apply the principles learned in the coronary care unit to the treatment of acute ischemic heart disease earlier in its course. Experience in the coronary care unit has shown that although death due to coronary heart disease may be sudden, it is not unannounced.3 That is, the commonest mode of death, ventricular fibrillation, is usually preceded by ventricular ectopic activity. Recognition of this prelude permits effective therapy to prevent ventricular fibrillation. If prevention fails, early recognition and promnpt therapy of ventricular fibrillation permits survival. Many different models of pre-hospital coronary care have been proposed and implemented throughout the world. At one end of the spectrum is the mobile coronary care unit, manned by physicians.4 This is the most expensive system, and is not applicable to many areas in the U.S. 512
The most prevalent system of pre-hospital coronary care in the U.S. today consists of ambulances manned by attendants who have taken the 81-hour Department of Transportation course for Emergency Medical Technicians (EMTs). EMTs are trained to perform cardio-pulmonary resuscitation (CPR) but are not trained to take EKGs, to defibrillate or to give drugs. Pozen's group elected to upgrade their Emergency Medical System (EMS) so as to allow the EMTs to provide definitive pre-hospital coronary care. They prepared 18 EMTs to become Cardiac Rescue Technicians (CRTs) by virtue of a 90hour advanced cardiac course. They were trained to identify patients who might have acute ischemic heart disease, and to institute EKG telemetry in these patients. They were also trained to recognize and treat (with telephone supervision by physicians) certain life-threatening complications of acute ischemic heart disease. These CRTs were then assigned to two ambulances that served a population of 125,000 people in Baltimore County. The ambulances were equipped with portable defibrillators and EKGs that were transmitted by telemetry to a teaching hospital. Two-way telephone contact between the ambulances and the base hospital was established. It was anticipated that this upgrading of the existent EMS would enhance the pre-hospital care of patients with acute ischemic heart disease in the population served by the system. When they evaluated the results of their first 22 months of operation, the results were quite disappointing. During that AJPH June, 1977, Vol. 67, No. 6
_ _
I~,m
W_
s s~~~~t~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ms fh
Established_191 J
.
w_ Svl_s ~_
June 1977 Volume 67, Number 6
Established 1911
Black Physicians and Black Communities EDITOR Alfred Yankauer, MD, MPH EDITORIAL BOARD
Michel A. Ibrahim, MD, PhD (1977)
Chairperson Rashi Fein, PhD (1978) Ruth B. Galanter, MCP (1977) H. Jack Geiger, MD, MSciHyg (1978) George E. Hardy, Jr., MD, MPH (1978) C. C. Johnson, Jr., MSCE (1977) Geroge M. Owen, MD (1979) Doris Roberts, PhD, MPH (1977) Pauline 0. Roberts, MD, MPH (1979) Ruth Roemer, JD (1978) Sam Shapiro (1979) Robert Sigmond (1979) Jeannette J. Simmons, MPH, DSc (1978) David H. Wegman, MD, MSOH (1979) Robert J. Weiss, MD (1977) STAFF
William H. McBeath, MD, MPH Executive DirectorlManaging Editor Allen J. Seeber Director of Publications Doyne Bailey Assistant Managing Editor Deborah Watkins Production Editor Janice Coleman Administrative Assistant CONTRIBUTING EDITORS George Rosen, MD, PhD Public Health: Then and Now William J. Curran, JD, SMHyg Public Health and the Law Jean Conelley Book Section
AJPH June, 1977, Vol. 67, No. 6
Dr. Lois Gray's article The Geographic and Functional Distribution of Black Physicians: Some Research and Policy Considerations which appears in this issue of the Journal' serves to underscore the lack of data on the distribution of black physicians in the United States. Aggregate data show a reasonably close match between the percentage of all physicians and the percentage of the population residing in four geographic regions of the country. However, these data indicate that the percentage of black physicians approximates the percentage of the population which is black in only one (North Central) region. Black physicians are more heavily concentrated in urbanized areas (92 per cent) than all physicians. This concentration is most marked in central cities (72 per cent) than in the urban fringe (20 per cent). Comparable figures for all physicians are 40 per cent and 36 per cent.' Less is known of the factors that influence the practice location decisions of black physicians. There is evidence to suggest that the racial characteristics of a community are less strongly correlated with the distribution of all physicians than are such factors as availability of hospitals and office space, and the average income of the population.2 It seems unlikely that black physicians would respond differently to these determinants of practice location. The existing concentration of black physicians may be a reflection of choice and continuing patterns of residential segregation, particularly in the North Central region of the United States. One would expect that if opportunities continue to improve for blacks to gain admission to medical schools and to prepare for the specialties of their choice, the distribution of black physicians will not be essentially different from that of all physicians. Does this mean that blacks will have even less access to black physicians? Probably not, given improvement in family income and access to good transportation. If black physicians do become less accessible to black communities, does it follow that the health of black communities will suffer? The answer to this question is less certain. It is well known that basic health indices show substantial deficits in the health status of blacks as compared with the rest of the population. However, health status indices such as infant mortality and life expectancy at birth are more strongly correlated with education and income than medical care. Most of the data used to construct health indices are not controlled for education or income. When income is taken into consideration, the differences between black and white indices are reduced but they do not disappear.3 When the percentages of the U.S. population never having received medically administered or prescribed preventive services are compared, the "black or other" category exhibits higher scores in six of seven services listed. However, the scores for black and other are lower than the scores for individuals with family income under $3,000 per annum for four of the seven services.5 While such comparisons must be interpreted with caution, it appears that both poverty and minority group status affect the utilization of preventive and other health services and that poverty is more important than race or ethnicity. The effect of poverty notwithstanding, in some areas of the United States there is still evidence of overt racial discrimination against blacks seeking medical care, and indications that blacks receive less thorough medical examina511
EDITORIALS
tions and that black women are more likely to undergo surgical procedures that result in sterilization.5 Given that the health indices of the black population are less favorable than those of the rest of the population and that this state of affairs cannot be explained wholly as an outcome of poverty, it should not be assumed that the answer lies in improving the access of the black population to black physicians. It is more likely that medically underserved populations, black or white, will benefit less from policies aimed at correcting physician maldistribution than they will benefit from policies designed (a) to ensure that the preferences of consumers are respected, (b) to eliminate finacial barriers to access to medical care, and (c) to increase the effectiveness and efficiency of the care provided. The health of all communities will improve as the environment is protected and the quality of individual and family life enhanced. The collection of health manpower data by race should be justified only as a means of monitoring equality of access to education for health careers. As Dr. Gray points out, inequalities in health services for black or white people, in rural or urban areas, are not the problem of black physicians; like
other inequalities in our society, they are the problem of us all.
ALONZO S. YERBY, MD, MPH
Address reprint tequests to Dr. Alonzo S. Yerby, Professor of Health Services Administration, Harvard School of Public Health, 677 Huntington Avenue, Boston, MA 02115.
REFERENCES 1. Gray, L. The geographic and functional distribution of black physicians: some research and policy considerations. Am. J. Public Health, 67:519-526, 1977. 2. Elesh, D. and Schollaert, P. T. Race and urban medicine: factors affecting the distribution of physicians in Chicago. J. Health and Social Behavior, Vol. 13, September, 1972. 3. Yerby, A. S. The Disadvantaged and Health Care. Am. J. Public Health, 56:5-9, 1966. 4. Selected Vital and Health Statistics in Poverty and Nonpoverty Areas of 19 Large Cities, United States, 1969-71, Vital and Health Statistics Series 21, No. 26. DHEW Publication No. (HRA) 761904. 5. Davis, K. and Marshall, R. Primary Health Care Services for Medically Underserved Populations. Papers of the National Health Guidelines: The Priorities of Section 1502. DHEW Publication No. (HRA) 77-641.
Pre-hospital Coronary Care The two reports by Pozen, et al." 2 in this issue of the Journal describe the implementation and early results of a telemetry ambulance system designed to improve pre-hospital care of patients with acute ischemic heart disease in southeast Baltimore county. The results of their efforts are of obvious import. The vast majority of acute cardiac ischemic events occur outside the hospital as do the majority of sudden deaths due to ischemic heart disease. For these reasons, programs aimed at improving the pre-hospital phase of the treatment of ischemic heart disease are of vital importance. The essence of the pre-hospital phase of coronary care is to apply the principles learned in the coronary care unit to the treatment of acute ischemic heart disease earlier in its course. Experience in the coronary care unit has shown that although death due to coronary heart disease may be sudden, it is not unannounced.3 That is, the commonest mode of death, ventricular fibrillation, is usually preceded by ventricular ectopic activity. Recognition of this prelude permits effective therapy to prevent ventricular fibrillation. If prevention fails, early recognition and promnpt therapy of ventricular fibrillation permits survival. Many different models of pre-hospital coronary care have been proposed and implemented throughout the world. At one end of the spectrum is the mobile coronary care unit, manned by physicians.4 This is the most expensive system, and is not applicable to many areas in the U.S. 512
The most prevalent system of pre-hospital coronary care in the U.S. today consists of ambulances manned by attendants who have taken the 81-hour Department of Transportation course for Emergency Medical Technicians (EMTs). EMTs are trained to perform cardio-pulmonary resuscitation (CPR) but are not trained to take EKGs, to defibrillate or to give drugs. Pozen's group elected to upgrade their Emergency Medical System (EMS) so as to allow the EMTs to provide definitive pre-hospital coronary care. They prepared 18 EMTs to become Cardiac Rescue Technicians (CRTs) by virtue of a 90hour advanced cardiac course. They were trained to identify patients who might have acute ischemic heart disease, and to institute EKG telemetry in these patients. They were also trained to recognize and treat (with telephone supervision by physicians) certain life-threatening complications of acute ischemic heart disease. These CRTs were then assigned to two ambulances that served a population of 125,000 people in Baltimore County. The ambulances were equipped with portable defibrillators and EKGs that were transmitted by telemetry to a teaching hospital. Two-way telephone contact between the ambulances and the base hospital was established. It was anticipated that this upgrading of the existent EMS would enhance the pre-hospital care of patients with acute ischemic heart disease in the population served by the system. When they evaluated the results of their first 22 months of operation, the results were quite disappointing. During that AJPH June, 1977, Vol. 67, No. 6
