The US healthcare system's racial legacy is plagued by significant disparities between patients of color and White patients that cross almost all medical conditions: cardiovascular disease, diabetes, cancer, HIV, mental health and kidney disease. The research data is abundant when comparing healthcare between Black and White patients. In fact, one of the most disturbing findings is that some disparities in healthcare services are associated directly with greater mortality among African Americans. Infant mortality, one of the nation's most critical gauges of maternal and societal health, is twice as common in Black communities than in White communities, and is prevalent throughout the entire socioeconomic range of the Black community.

For people of color, this is the grim state of healthcare in the US today:

• Primary Care
  About 30 percent of Hispanic and 20 percent of Black Americans lack a usual source of health care compared with less than 16 percent of Whites. Hispanic children are nearly three times as likely as non-Hispanic White children to have no usual source of health care. African Americans and Hispanic Americans are far more likely to rely on hospitals or clinics for their usual source of care than are White Americans (16 and 13 percent, respectively, versus 8 percent).
• Heart disease
  African Americans are 13 percent less likely to undergo coronary angioplasty and one-third less likely to undergo bypass surgery than are Whites.
• Asthma Among preschool children hospitalized for asthma, only 7 percent of Black and 2 percent of Hispanic children, compared with 21 percent of White children, are prescribed routine medications that will prevent future asthma-related hospitalizations.
• Breast cancer
  For Asian American, Black, and Hispanic women, the length of time that passes between when she has a mammogram that indicates a possible abnormality and when her follow-up diagnostic test is conducted to determine whether she actually has breast cancer is more than double the waiting time for White women.
• Human immunodeficiency virus (HIV) infection
  African Americans with HIV are less likely to be on antiretroviral therapy, less likely to receive prophylaxis for Pneumocystis pneumonia, and less likely to be receiving protease inhibitors than other persons with HIV. [An HIV infection data coordinating center, now under development, will allow researchers to compare contemporary data on HIV care to examine whether disparities in care among groups are being addressed and to identify any new patterns in treatment that might arise.]
• Nursing home care
  Asian American, Hispanic, and African American residents of nursing homes are all far less likely than White residents to have sensory and communication aids, such as glasses and hearing aids. [A new study of nursing home care is developing measures of disparities in this care setting and their relationship to quality of care.]

(Addressing Racial and Ethnic Disparities in Health Care. Fact Sheet, February 2000. AHRQ Publication No. 00-PO41. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/disparit.htm )

The Institute on Medicine's 2002 publication Unequal Treatment examined well over 100 studies that assessed the quality of healthcare for racial and ethnic minorities. This report, similar to many others, states that, in addition to major differences in health outcomes (some of which have been mentioned above), analyzing the causes for these differences has unearthed some disturbing results. As might be expected, one source for these disparities includes the patient's socioeconomic position (SEP). SEP provides a composite picture by capturing data such as income and wealth, education, class, occupation, and neighborhood poverty concentration. Generally, people with higher SEP fair better than the poor or people with lower SEP; and Blacks are disproportionately poor. Other potential sources include the patient's risk behavior and whether or not s/he has good health insurance coverage (or any coverage at all). The report found, however, that these factors, along with genetics, cannot explain completely the trends in racial and ethnic differences in health.

Some factors seem to be related to the history of and continuing presence of institutional racism. The IOM report states "Researchers also have long speculated that the stressful effects of racial and ethnic discrimination and marginalization in American society could underlie some of the racial differences in health. Indeed, in recent decades, studies have begun to describe increasingly complex physiologic pathways that connect stress with adverse health outcomes." Even access to health care goes beyond whether or not people have health insurance and includes such factors as the willingness of physicians to accept certain types of insurance (e.g., Medicaid), the geographic location of services, and the knowledge of and attitudes towards patients of color. Studies have shown that physicians of color are more likely to serve patients of color and are also more likely to serve poorer patients. Unfortunately, Blacks and Hispanics remain seriously underrepresented in the health professions, including the ranks of physicians. Here the history of segregated schools in the United States has played an important role. So, too, even environmental and occupational exposures that may impact health status have been linked to racial factors. Some studies have shown that hazardous waste sites are more likely to be placed in communities of color and that some racial minorities are much more likely to hold jobs that pose occupational risks to their health; although, in truth, the research in these areas has been limited.

What is beyond doubt, though, are the disturbing findings related to the quality of care. Why is it that Black Americans are less likely to be accorded a number of key medical procedures and that in studies patients with identical presentations received radically different diagnosis and treatment? The answer is a complex one since so many factors contribute to disparities in health. However, to begin to address these deficiencies, there is an increasing amount of attention being paid to the topic of cultural competence, which refers to the quality of interaction between provider and patient. Although this newly emerging focus on cultural competence is an important consideration for providing quality healthcare to patients of color, it addresses only certain contributing factors. Misdiagnosis and inadequate treatment may result from provider bias and ignorance; just as some disparities may be the result of historically flawed systems that limit access to healthcare in certain geographic areas and that provide inferior services to people of color. In some instances, the quality of care is influenced not only by the interaction between the doctor and the patient but also by the way the institution itself operates. Service hours, staffing, management policies and procedures that govern overall operations, and the "organizational culture" of the healthcare system all contribute to unequal outcomes. Only by examining issues of institutionalized racism within the system itself can practitioners, administrators and policymakers begin to understand how system-wide policies, as well as provider-specific practices and behaviors, undermine the provision of quality care to patients of color, their families and their communities.