The Health Equity Agenda is a Bad Prescription

The job of medicine is to promote patients’ health: that is doctors’ contribution to social justice.

The disparities in health outcomes in the US, most notably between black and white, is appalling. It is an effect of our country’s original sin, compounded by hundreds of years of racism. Whether you examine specific health issues -- COVID, gun violence, cardiovascular death – or overall mortality, the differences are repugnant, embarrassing, and heart breaking.

I hope I have had some effect on lessening these disparities during my clinical career. I am proud of the research that many of my colleagues have done to delineate the disparities and discover ways of lessening them.

In this post, Dr. Sally Satel argues that some health disparities research is flawed, drawing unfounded conclusions, and suggesting solutions that might actually harm the people the researchers intend to help. She calls for better research and also questions the physician’s role beyond caring for patients.

Adam Cifu

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Methadone has been used for decades as treatment for heroin addiction. The long-acting synthetic opioid is given daily to block withdrawal symptoms and drug craving. Patients attend a methadone clinic every day to get their dose and, as they demonstrate reliability and growing commitment to the treatment program can earn increasing numbers of “take home” doses, up to a full month. The staff balance the earned freedom with the risk that a patient might sell their methadone or combine it with other drugs.

During COVID-19, federal government issued a new guidance for methadone clinics, in an effort to decrease infection risk. Whereas before the pandemic, even patients in good standing had to wait months before they could get a single “take-home” bottle per week, the new rule allowed “stable” patients, as the guidance called them, an entire month of take-home doses within a matter of weeks.

A research team decided to examine the distribution of take-home privileges by race. As they reported recently in JAMA Network Open, Black methadone patients on Medicare were less likely to receive take homes than white and Hispanic patients. The authors speculated upon possible reasons why this might have been the case:  not all clinics necessarily adopted the new, more lenient policy, some patients may have preferred to attend daily, perhaps there was racial and ethnic bias on the part of the staff, and, critically, it was unlikely that all patients were deemed stable enough for take-homes.

Yet absent any clues about the relative contribution of these potential variables to the outcome – the racial distribution of take-homes -- the authors concluded that, “Our findings highlight the imperative to reduce inequities in [Opioid Use Disorder] treatment.”   

This is a problem. It is one thing to generate hypotheses about why disparities in health practices or outcomes exist, but wholly another to infer bad faith -- “inequity” – as their cause without adequate information.

This paper is certainly not an isolated example. A 2023 meta-analysis targeting six studies found that Black patients were physically restrained in the emergency room more often than patients of other racial groups. However, the authors could not link use of restraint to agitated psychosis – a common reason for restraint – because the studies included in the analysis reported their data in aggregate form. Despite this formidable limitation, the authors concluded that, “methods to address racism at all levels (individual, institutional, and systemic) should be considered.”

Attributing disparities to racism is routine. The CDC deems racism “a public health threat” because it leads to disparities. The University of Michigan’s Center for Antiracism Research for Health Equity identifies "structural racism as a fundamental cause of health inequities." The Senior Vice President of the American Medical Association says that “[R]acism — as a system of power and oppression embedded into policies and culture — is at the root of [health] inequities.”

There is no question that the poorer health and lower access to care suffered, in the aggregate, by Black Americans is partly due to the legal, political, and social institutions that have historically discriminated against them. At times, inferior treatment has been explicit and at other times passively inflicted through disregard of the differential brunt of policies.

But systemic racism is neither an actionable diagnosis nor a valid explanation of every disparity. After all, factors that initiate problems are not necessarily the ones sustaining them.

Only when researchers bring causal dynamics into sharp focus can health professionals know which points of entry into the healthcare system can help them minimize inter-group discrepancies in health care and health outcomes.

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Readiness to invoke racism as the cause of health disparities is accompanied by a tendency to propose dubious, and potentially unconstitutional, policies to address the disparities.

Recall that during COVID-19, national experts argued for giving priority to minority patients in distributing the new vaccine. Their plan would have delayed vaccination of elderly, highest risk, individuals solely because whites were over-represented among the aged. Overall, more deaths would have likely resulted.

Other promoters of health equity lobbied for a rationing scheme that prioritized the assignment of ventilators to Black patients, negating customary triage procedures. Physicians have spoken openly of a role for reparations in health care decision-making more generally.

Last spring, doctors at Massachusetts General Brigham stopped reporting to child welfare officials suspected incidents of abuse or neglect solely on the grounds that a mother exposed her fetus, or a newborn, to drugs. Why? According to the United Against Racism program at the medical center, “Black pregnant people are more likely to be drug tested and to be reported to child welfare systems than white pregnant people.” The director of substance abuse services at the hospital described the policy as “the latest step in our efforts to address long-standing inequities in substance use disorder care.” 

What to do about suspected fetal exposure is a thorny issue. But because hospital staff presumed racism as the sole culprit, they implemented the new protocol as fixed policy, without, to my knowledge, having conducted a pilot to determine how babies and mothers would fare under a relaxed system.

Had they done so, they might have found that Black women were indeed tested in an inappropriate manner and that correcting the error yielded better outcomes for Black mothers and babies. Or, maybe, evidence would have shown that white women needed to be tested more frequently. Perhaps they would have identified complex reasons that Black mothers are at higher risk of drug use (and found ways to address them). In the absence of such data, disparate impact alone should not drive drug testing, or any other treatment policy.

Finally, reducing gaps is, in itself, a questionable goal. For example, if the health of whites and Blacks improve in tandem, leaving the disparity intact, the disparity lens would blind us to the overall progress made for both groups. Conversely, is it worth celebrating a narrowed gap that is due to a decline in the health of whites?

Nor is it always clear that disparities suggest lesser quality of care. Well-insured whites are more likely to undergo needless interventions, but it would be pernicious to subject non-whites to an equal number of needless interventions in the name of equity.

The project to shrink health disparities is seriously troubled. Its efforts to examine the causes of disparities are scientifically uneven, its reflexive attribution of differential health status to racism or systemic racism is ineffectual, and many of its proposals to close gaps are clinically misdirected.

The big question, then, is whether the current preoccupation with health disparities is justified.

As a physician, my care for patients has nothing at all to do with the relative health of groups. The only gap that concerns me is the discrepancy between a patient’s current and optimal health. This should be our guiding philosophy more broadly: improved access to quality care for the sickest and underserved, across the board.

Yes, researchers should continue to identify and explore group-based health gaps, but they should also be humble about their capacity to interpret detail-limited, retrospective data. Also, they must be more open to the possibility that patient choice and innate biological factors (that roughly vary by group) can be as powerful as social conditions, depending upon the particular disparity in question.

As for closing health gaps, the American Medical Association’s directive that physicians “dismantle racism” is unworkable. Doctors’ primary job is to diagnose and to treat, and to do no harm in the process. Researchers need to give doctors and healthcare systems discrete variables they can test, and eventually use – not for the purpose of shrinking gaps, but to serve all patients better.

Questioning the health equity agenda may be seen as sacrilege. But let’s be clear – the job of medicine is to promote patients’ health: that is doctors’ contribution to social justice. If patients learn that their doctors’ loyalties have been subordinated to concerns about identity politics, the profession will squander even more of the public’s precious trust.

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Sally Satel is a psychiatrist and senior fellow at the American Enterprise Institute and a lecturer at Yale University School of Medicine. 

Photo Credit: Annie Spratt