Rheum and Race: Where Are We?

A paper by Fry and colleagues published in Arthritis Care & Research (AC&R) deserves the attention of ACR members.¹ The title is a mouthful: “Racial/ethnic disparities in patient-reported nonsteroidal antiinflammatory drug (NSAID) risk awareness, patient-doctor NSAID risk communication, and NSAID risk behavior.” The message, however, is simple: African American patients who were prescribed NSAIDs received less education about medication toxicity and fewer prescriptions for medications to prevent gastrointestinal complications than did white patients. While income and educational levels were important, these factors did not account for much of the racial disparity that was found.

Several other recent papers in AC&R have documented additional examples of racial disparities in both the impact of rheumatic diseases and the utilization of rheumatologic and orthopedic care. A recent paper in the Journal of Rheumatology reported that the median time from the diagnosis of rheumatoid arthritis to the initiation of disease-modifying anti-rheumatic drugs was seven years for non-white versus one year for white patients.² This discrepancy represents, in part, differing approaches to treatment in a “private clinic,” which took care of a patient population that was mostly white, versus a “public clinic,” where primarily minority patients were treated.

Multiple barriers limit access to medical care, and these barriers affect different portions of our society asymmetrically. However, what these studies report bears on what happens after patients reach a physician. Moreover, the results could not be attributed to patients of different racial groups receiving care from different physicians.

Race a Pervasive Issue for Medicine

These disparities are not unique to the practice of rheumatology. Similar results have been repeatedly documented in many domains of healthcare, and appear to be narrowing only slowly. And, as reported by ABC News, the disparities in healthcare delivery are also mirrored in the spectrum of patients who participate in clinical research trials.³

Superimposed on this problem is the healthcare crisis manifested by the expanding number of Americans who lack medical insurance. According to January’s Congressional Quarterly, which summarizes a study performed by the Urban Institute, 27,000 Americans were estimated to have died in 2006 because they did not have health insurance, compared to 18,000 in 2001.⁴ A 50% increase in five years is a statistic that is both sobering and shameful.

A recent editorial published in AC&R, titled “Articulating a justice ethic for rheumatology: A critical analysis of disparities in rheumatic diseases,” also addresses equity in healthcare.⁵ Rom and colleagues trace the axiom that preservation of health is the foundation for a just society back to the French philosopher Rene Descartes and argue that ensuring equitable access to healthcare is a fundamental issue of social justice. They further argue that disparities in outcomes of rheumatic disease are, in substantial measure, “avoidable, unnecessary, and unfair.”