Opinion
Editorials represent the opinions of the authors and JAMA and not those of the American Medical Association.
EDITORIAL
Race, Poverty, and Medicine in the United States Howard Bauchner, MD
I spent most of my career at the Boston City Hospital, now known as Boston Medical Center, that has emphasized “exceptional care without exception.” At Boston City Hospital the 2 worlds of race and poverty collide on an almost daily basis. Under the 4-decade leadership of 2 pediatric chairs, Joel Alpert, MD, and Barry Zuckerman, MD, and Viewpoints pages 1415 and continuing under the cur1417 rent chair Robert Vinci, MD, the Department of Pediatrics expanded the boundaries of traditional medicine. In addition to providing care for medical problems such as asthma, HIV/AIDS, seizures, prematurity, and sickle cell disease, the department is committed to addressing issues of poverty, violence, poor housing, and food insecurity. In this issue of JAMA, 2 Viewpoints address social determinants of health.1 The Viewpoint by Martin and colleagues2 focuses on the health of young African American men, whereas the Viewpoint by Wong and colleagues3 is broader, focusing on how to design a health care system that achieves equity—1 of the 6 principles articulated in 2001 by the Institute of Medicine in Crossing the Quality Chasm: A New Health System for the 21st Century. 4 Where has the debate been about equity and disparities in health and health care? Have these issues slipped into the shadows because of health care reform? Certainly no one believes that simply extending health care to more individuals will reduce many of these disparities. Much more is needed to address the substantial differences in health status and health outcomes related to race, ethnicity, and poverty in the United States. Are there solutions? One approach is suggested in the article by Martin and colleagues—many African American men do well—1 of 3 goes to college, 3 of 4 are drug free, 5 of 9 have jobs, 7 of 8 are not teenaged fathers, and 11 of 12 finish high school.2 Perhaps it is time to return to the older concept
of resiliency. Many people who face racism and poverty still achieve. They work, they raise families, they contribute to society. This is not meant to minimize the extraordinary effort it takes for those individuals to succeed. One goal of medicine is to better understand resiliency and to support it so that all people can fulfill their potential and enjoy healthy and productive lives. There is some good news. For the first time in decades the number of individuals being incarcerated in the United States is declining. Is there less crime? Or is the approach to crime changing? States have come to recognize the substantial financial burden of incarcerating large numbers of their citizens. As noted in the Viewpoint by Martin and colleagues, as either a consequence or cause, incarceration leads to a cascade of events that makes achievement in life very difficult.2 Many have championed the patient-centered medical home. The jury remains out about this approach. The data are inconclusive, even for traditional medical problems like hypertension and congestive heart failure.5,6 It is unlikely that the patient-centered medical home or other emerging trends in medicine, such as the use of big data, personalized medicine, or the emphasis on value vs volume in payment, will solve the problems of disparities in health and health care and achieve equity, unless the surrounding conditions that patients return to everyday in their lives—poor housing, violence, and poverty—change. Indeed, some of the emerging trends in medicine may exacerbate rather than ameliorate health care disparities. That is why it is critical, as Wong and colleagues argue, for physicians and health care organizations to be aware of underlying causes of poor health and think creatively about how to ensure equity. No radical solutions are offered in this Editorial or the 2 related Viewpoints because none exist. Rather, the goal of publishing these articles is to rekindle the much-needed debate in the United States about race, poverty, and medicine.
ARTICLE INFORMATION
REFERENCES
Author Affiliation: Editor in Chief, JAMA.
1. Marmot MG, Bell R. Action on health disparities in the United States: Commission on Social Determinants of Health. JAMA. 2009;301(11): 1169-1171.
Corresponding Author: Howard Bauchner, MD, Editor in Chief, JAMA, 330 N Wabash Ave, Chicago, IL 60611 ([email protected]). Published Online: March 9, 2015. doi:10.1001/jama.2015.2262. Conflict of Interest Disclosures: Dr Bauchner has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
2. Martin SA, Harris K, Jack BW. The health of young African American men. JAMA. doi:10.1001 /jama.2015.2258. 3. Wong WF, LaVeist TA, Sharfstein JM. Achieving health equity by design. JAMA. doi:10.1001/jama .2015.2434.
http://www.nap.edu/catalog/10027.html. Accessed February 25, 2015. 5. Friedberg MW, Schneider EC, Rosenthal MB, Volpp KG, Werner RM. Association between participation in a multipayer medical home intervention and changes in quality, utilization, and costs of care. JAMA. 2014;311(8):815-825. 6. Schwenk TL. The patient-centered medical home: one size does not fit all. JAMA. 2014;311(8): 802-803.
4. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century.
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(Reprinted) JAMA April 14, 2015 Volume 313, Number 14
Copyright 2015 American Medical Association. All rights reserved.
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Editorials represent the opinions of the authors and JAMA and not those of the American Medical Association.
EDITORIAL
Race, Poverty, and Medicine in the United States Howard Bauchner, MD
I spent most of my career at the Boston City Hospital, now known as Boston Medical Center, that has emphasized “exceptional care without exception.” At Boston City Hospital the 2 worlds of race and poverty collide on an almost daily basis. Under the 4-decade leadership of 2 pediatric chairs, Joel Alpert, MD, and Barry Zuckerman, MD, and Viewpoints pages 1415 and continuing under the cur1417 rent chair Robert Vinci, MD, the Department of Pediatrics expanded the boundaries of traditional medicine. In addition to providing care for medical problems such as asthma, HIV/AIDS, seizures, prematurity, and sickle cell disease, the department is committed to addressing issues of poverty, violence, poor housing, and food insecurity. In this issue of JAMA, 2 Viewpoints address social determinants of health.1 The Viewpoint by Martin and colleagues2 focuses on the health of young African American men, whereas the Viewpoint by Wong and colleagues3 is broader, focusing on how to design a health care system that achieves equity—1 of the 6 principles articulated in 2001 by the Institute of Medicine in Crossing the Quality Chasm: A New Health System for the 21st Century. 4 Where has the debate been about equity and disparities in health and health care? Have these issues slipped into the shadows because of health care reform? Certainly no one believes that simply extending health care to more individuals will reduce many of these disparities. Much more is needed to address the substantial differences in health status and health outcomes related to race, ethnicity, and poverty in the United States. Are there solutions? One approach is suggested in the article by Martin and colleagues—many African American men do well—1 of 3 goes to college, 3 of 4 are drug free, 5 of 9 have jobs, 7 of 8 are not teenaged fathers, and 11 of 12 finish high school.2 Perhaps it is time to return to the older concept
of resiliency. Many people who face racism and poverty still achieve. They work, they raise families, they contribute to society. This is not meant to minimize the extraordinary effort it takes for those individuals to succeed. One goal of medicine is to better understand resiliency and to support it so that all people can fulfill their potential and enjoy healthy and productive lives. There is some good news. For the first time in decades the number of individuals being incarcerated in the United States is declining. Is there less crime? Or is the approach to crime changing? States have come to recognize the substantial financial burden of incarcerating large numbers of their citizens. As noted in the Viewpoint by Martin and colleagues, as either a consequence or cause, incarceration leads to a cascade of events that makes achievement in life very difficult.2 Many have championed the patient-centered medical home. The jury remains out about this approach. The data are inconclusive, even for traditional medical problems like hypertension and congestive heart failure.5,6 It is unlikely that the patient-centered medical home or other emerging trends in medicine, such as the use of big data, personalized medicine, or the emphasis on value vs volume in payment, will solve the problems of disparities in health and health care and achieve equity, unless the surrounding conditions that patients return to everyday in their lives—poor housing, violence, and poverty—change. Indeed, some of the emerging trends in medicine may exacerbate rather than ameliorate health care disparities. That is why it is critical, as Wong and colleagues argue, for physicians and health care organizations to be aware of underlying causes of poor health and think creatively about how to ensure equity. No radical solutions are offered in this Editorial or the 2 related Viewpoints because none exist. Rather, the goal of publishing these articles is to rekindle the much-needed debate in the United States about race, poverty, and medicine.
ARTICLE INFORMATION
REFERENCES
Author Affiliation: Editor in Chief, JAMA.
1. Marmot MG, Bell R. Action on health disparities in the United States: Commission on Social Determinants of Health. JAMA. 2009;301(11): 1169-1171.
Corresponding Author: Howard Bauchner, MD, Editor in Chief, JAMA, 330 N Wabash Ave, Chicago, IL 60611 ([email protected]). Published Online: March 9, 2015. doi:10.1001/jama.2015.2262. Conflict of Interest Disclosures: Dr Bauchner has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
2. Martin SA, Harris K, Jack BW. The health of young African American men. JAMA. doi:10.1001 /jama.2015.2258. 3. Wong WF, LaVeist TA, Sharfstein JM. Achieving health equity by design. JAMA. doi:10.1001/jama .2015.2434.
http://www.nap.edu/catalog/10027.html. Accessed February 25, 2015. 5. Friedberg MW, Schneider EC, Rosenthal MB, Volpp KG, Werner RM. Association between participation in a multipayer medical home intervention and changes in quality, utilization, and costs of care. JAMA. 2014;311(8):815-825. 6. Schwenk TL. The patient-centered medical home: one size does not fit all. JAMA. 2014;311(8): 802-803.
4. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century.
jama.com
(Reprinted) JAMA April 14, 2015 Volume 313, Number 14
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Eastern Kentucky University User on 05/30/2015
1423
