Structural Healthcare Disparities: International Perspectives, Issues, Challenges, and Ways Forward

Introduction (Lubna Mirza, MD, Endocrinologist at Norman Regional Health System, United States)

George Perry Floyd Jr. was a black man choked to death by a police officer in Minneapolis, MN, during an arrest after a store clerk suspected Floyd used a counterfeit $20 bill, on May 25, 2020.

The killing of George Floyd fueled the Black Lives Matter movement and elevated public awareness of racism throughout society.  As part of this, the medical community increased its consciousness of structural disparities in healthcare outcomes. Studies consistently show worse healthcare outcomes for black people, minorities and women in various medical settings.

Healthcare disparities include differences in access to or availability of medical facilities and differences in how various populations are served. Also, there are differences in rates of disease occurrence and disabilities among population groups based on socioeconomic class, age, ethnicity, gender, and financial resources.

Racism, colorism and sexism are not uniquely American problems. They are international human issues affecting the lives of millions adversely.

Members of our International Endocrine Class offer here the following personal observations of healthcare inequities and proposals for interventions to improve access and reduce morbidity and mortality in underserved communities.

My Experience (Rakesh Kumar Shah, MBBS, Nepal)

I worked in one of the rural health centers in Nepal for nearly two and a half years. Later, I came to the United States to do an internship in one of its community hospitals. I also had the opportunity to volunteer in two free clinics in the greater Oklahoma City area. Thus, I have observed inequities internationally in various healthcare settings.

In Nepal, some patients were able to come to the medical center in private cars, while others had to walk for miles. Despite medical services being highly subsidized by the government of Nepal, it was still difficult for some people to afford the health services. Many were unable to pay for some needed basic medical supplies.

The coverage of health insurance is very poor and people mostly have to pay out of their own pockets. There are also those who did not believe in the effectiveness of government health services and were more interested in seeking healthcare at expensive private hospitals. These disparities were always linked to differences in socio-economic conditions, ethnicity and geographical structures.

Before coming to the United States, I had mostly heard of the better healthcare available there. After arriving in the U.S. and working in a free health clinic, I came to see that America, too,  has healthcare delivery problems. These were mostly the barriers some experience to quality healthcare accessibility.

A good thing about healthcare in the U.S., I found, was the general availability of technology such as continuous glucose monitoring devices (CGM), insulin pumps and newer diabetes drugs, resulting in better disease control outcomes. However, there were many underserved populations who were deprived of even minimal health services. Those populations were supported by free clinics like Manos Juntas in Oklahoma City.

History of Healthcare Disparities (Tanya Amal, MBBS. India)

Health care disparities have existed since the dawn of time. However, in the 1900s with the advent of health care awareness, these disparities came to the surface in the Indian subcontinent.

The Bhore Committee under Dr. Joseph Bhore was set up to evaluate and improve health care policies in India. Thus was revealed the irregularities in health care that were attributed to poverty, caste discrimination and lack of education. These socioeconomic stratifiers were the shackles holding back the nation from modernization. The advent of modern Indian political parties added yet another criteria by which patients would be screened. Even today, rural India has pockets where healthcare is divided: people from a particular caste/religion have their own group of doctors. It is not unusual for a doctor from one community to refuse to see a patient from another community.

In America, in the 1900s, health care disparities emerged as a universal issue. In 1932, the US Public Health Service Department started the Tuskegee study in Black males for untreated Syphilis. This study deprived its participants of the benefits of Penicillin for decades, even though it had become widely available by 1945.

Long before, in the 1840s, Dr James Marion Sims performed multiple surgeries on Black women without anesthesia. He is once said to have remarked “There was never a time that I could not, at any day, have had a subject for operation.” He noted this to be the most “memorable time” of his life.

The horrific injustices inflicted upon the Jewish community during the Holocaust are well known. Time and time again, ethnicity and economic background have ruled the arena of health care disparities. While these anecdotes highlight the gross negligence that have led to reforms in healthcare delivery, healthcare disparities still continue in various shapes and forms around the world.

Current Scenario (Dr. Anil KC, MBBS, Nepal)

Disparities in healthcare in Nepal take a variety of forms, despite the fact that they are rarely discussed. In my experience at the workplace, people who are marginalized and from low-income communities suffer the most because of the cost of treatment they have to bear if they get sick. In addition, the majority of the poor population lives in remote places, necessitating several days of walking to reach a healthcare facility. Vehicle transportation may be just unavailable to the poor and marginalized community. Even though the government covers pregnancy care and delivery at a minimal cost in Nepal, transportation costs are overlooked, making things more difficult for the poor.

I have seen people with simple traumas living lives of disability since they avoid healthcare due to the high treatment cost. All disease processes are inevitable and can happen to anyone at any time, regardless of their socioeconomic status. In some cases, impoverished people choose to die rather than leave the debt to their family. It is painful to consider that some poor people pay with their lives, even though it was not their fault. Unavailability of most of the essential free medicine and commodities at government health institutions  – and poor health insurance policy – make it even more difficult to get health care service by a poor population due to financial barriers.

For the last five years, I’ve been working in rural areas of Nepal, where I have seen private medical clinics administer antibiotics through intravenous lines to poor and uneducated people just to make money, even when there is no evidence of infection.

Gender inequality is another form of disparity commonly seen at my workplace. Pregnant women receive minimal care due to gender-based inequality as females are mistreated by their families and many female rape victims are paid by the abuser to keep their mouths shut to avoid going to court.

My Perspective Ayfa Riaz Bajwa, MBBS, Pakistan

After my graduation, I worked at the Allied Hospital in Faisalabad, Pakistan. This hospital serves the industrial city of Faisalabad as well as the surrounding rural areas. Sometimes it’s hard for people in serious conditions to make their way to the hospital. Especially for diseases requiring continuous monitoring and follow-up. Even if they did make it to the hospital, due to the unfortunate reality of healthcare in Pakistan, they needed personal connections with medical staff to get attention. Without knowing doctors or nurses personally, it is really difficult for middle-class citizens to get medical attention at a hospital, let alone someone living below the poverty line.

In the United States, despite the rosy image of America portrayed in movies worldwide, when I moved there, I was surprised to find similar disparities. Lower income patients who cannot afford health insurance must go to free clinics with limited resources which cannot provide specialist care to these patients even with serious illnesses.

Although my family of three cannot claim to have the same experiences as those belonging to the underserved community, we came really close. As dependents of a Ph.D. student in Los Angeles, our monthly salary placed us just below the federal poverty line for a family of three. Private health insurance was out of reach and visa restrictions prevented us from taking state-subsidized health insurance. The only services available to us were through community clinics and other clinics run by the USC medical and dental school meant for their students to get hands-on experience. The quality of care here was dependent on the quality of the student.

Although structural and health care disparities have been as old in America as the history of racism itself, they became more obvious during the pandemic. As COVID19 spread everywhere, communities of color were hit harder than the others. Various faulty assumptions were used to rationalize the situation such as blaming untidy living habits. In reality, these were simply lower income communities which didn’t have luxury working at home, most of them being frontline workers dealing with customers in-person and regularly using public transportation.

COVID-19 and the Rise of Healthcare Disparities (Valbona Biba, MD, Albania)

COVID-19 does not discriminate based on race and socioeconomic status, but the U.S. healthcare system does!

With the significant health consequences seen secondary to COVID-19, studies show that healthcare disparities in the U.S. have been further exacerbated. Various explanations have been proposed to account for increased disparities seen during the COVID-19 pandemic. Not only are infection rates higher in Black populations and marginalized populations, but consequences and complications after COVID-19 infection are significantly elevated there as well. Some Black populations are hospitalized after COVID 19 infection at a rate more than threefold higher than white populations.  It is also important to note that people in these communities often live in higher-density environments and experience poorer access to insurance and health care. These issues are further compounded by the inherent mistrust of the medical field that exists in Black communities in response to decades of racist actions and policies that have negatively impacted marginalized groups.

In Albania, the race of the population is homogenous and consequently not a factor causing healthcare disparities. I have not worked in healthcare centers treating patients infected by COVID-19, and there is no study about healthcare disparities in Albania yet. However, what has caught my attention are complaints of many people on TV, social media, and those around me, that the more money you give to a hospital, the better service you get! And if not giving money to them, these people are not treated properly. Unfortunately, many people in my country hospitalized for severe COVID-19 infection have spent and even borrowed money to get better medical treatment.

The Changing Perception: (Deepa Luitel, MBBS, Nepal)

Most of the healthcare disparities worldwide are based on racism, sexism, caste systems, ethnicities, and inequities between rich and poor. In developed nations due to the high cost of healthcare, the poor and marginalized population cannot afford a doctor, insurance, and even copays for their prescription.

In developing countries, lack of health education, health care facilities, and transportation challenges remain the most important reasons behind reduced healthcare utilization. Whether from natural disasters, endemics, or the COVID-19 pandemic, poor and marginalized populations are the ones who mostly bear consequences of healthcare disparities. Unhealthy lifestyles and behaviors, along with inadequate healthcare also contribute to health care disparities in such populations.

The U.S. implemented the “Affordable Care Act ” also called as “Obamacare,” on March 23, 2010. This provided affordable health care to low-income households. There are also many free clinics in the U.S. where patients can get free preventive care and maximum health coverage often at a low cost.

Medicare in the U.S. covers nearly 64 million people, the federal health insurance program for the elderly (age>65 years), disabled, and those diagnosed with end-stage renal disease.

Medicaid, which covers low-income households including pregnant women, children, and people with disabilities, has increased to 72 million.

Due to the recent advancement in technologies and rapid urbanization in developing countries, opportunities are improving in areas like poverty reduction, health education, and social mobility. There is also improvement in healthcare access and increased healthcare utilization. It is wise to consider the need for economic advancement and educational opportunities in underserved populations to be able to minimize disparities in health and healthcare in the near future.

What Can Be Done? ( Shrinkhala Maharjan, MBBS, Nepal)

The socioeconomic imbalance prevalent for centuries has had a major impact on health care disparity all over the world and into the present. The setback faced due to inadequate economy creates a multifactorial pathway to diminishing health status of a person. Having worked in semi-government, private and one military hospital in Nepal, I have observed the pro-rich nature of health care here. Addressing this will require thorough policy improvements, addressing stratification in its various aspects.

#  The first step invariably is building a proper education system. Especially consider:

• Primary education should be a human right, every child deserves the right to be literate.
• In this time with technological breakthroughs, availability and reachability of different forms of information and education should be universally available.
• Utilization of digital technology should make health care information more accessible.
• Because women are the core of a family, educating and empowering them will improve the health status of entire families.

# Understanding social determinants of health.

• Acknowledge the unique challenges of every patient. From the early days of the training physicians should be prepared and a system integrated for dealing with people of different social, racial, economic and cultural backgrounds.

# Distribution of manpower.

• The indisputable inequality of healthcare facilities in rural areas throughout the U.S. needs to be addressed, with mobilization and utilization of the existing manpower. About 20% of the U.S. population lives in rural areas, but only 9% of the nation’s physicians practice in rural communities.

# Raising awareness on the available health care resources and facilities to the underprivileged people.

• Medicaid accounts ~15% of medical expenses in America. Medicaid is a support system for nearly 7 million low-income people with severe disabilities. The lack of awareness about its availability is prevalent, diminishing the utilization of these resources.

With special thanks to Nathaniel Batchelder for editing this paper