Leslie had put the worst face of black America: Pervasive negative stereotypes about black people are as old as our nation. As more black people have ascended into the middle class since the civil rights era, tensions have arisen between middle-class blacks and their poorer counterparts. See Lawrence Otis Graham, Member of the Club (New York: Harper Collins, 1995); Eugene Robinson, Disintegration (New York: Doubleday, 2010) and Sheryll Cashin, The Failures of Integration (New York: Public Affairs, 2004).
as they were at many community clinics back then: These community clinics historically had served poor black patients. Over the last 15 years, however, North Carolina has seen a rapid influx of Hispanic residents. In 1990, Hispanics made up 1.2 percent of the state’s population; in 2000, it had risen to 4.7 percent; by 2010, it had climbed to 8.4 percent. Between 2000 and 2010, North Carolina had the sixth greatest Hispanic population growth in the nation; http://censusscope.org/2010Census/states.php?state=NC&name=North%20Carolina http://ui.uncc.edu/sites/default/files/pdf/NCCensus2010.pdf.
As male medical students, we’d been told to have a female staff member: For a thorough discussion about the complexity of male physicians examining female patients, see Atul Gawande, Better (New York: Henry Holt and Company, 2007).
More than 70 percent of black children are born to unmarried women: According to 2010 data from the Department of Health and Human Services, 72 percent of black children are born outside marriage, compared with 53 percent of Hispanics and 29 percent of whites. See National Vital Statistics Report, Births: Final Data for 2010 61, no.1 (August 2012); http://www.cdc.gov/nchs/data/nvsr/nvsr61/nvsr61_01.pdf.
Many people use these numbers as a statement about the breakdown of black communities: For what would be considered a traditional African American perspective, see Juan Williams, Enough (New York: Crown Publishers, 2006). See also Bill Cosby and Alvin Poussaint, Come On, People (Nashville: Thomas Nelson, 2007). For other conservative views on the subject, see Shelby Steele, A Dream Deferred (New York: Harper Collins, 1998), and John McWhorter, Winning the Race (New York: Gotham Books, 2005). For a more left-leaning analysis, see Eugene Robinson, Disintegration.
the rates among black teens remained more than twice that seen among white teens: National Vital Statistics Report, Births: Final Data for 2010.
potentially dangerous sexually transmitted infections: Untreated gonorrhea and chlamydia in pregnancy are associated with a variety of possible complications, including premature birth and low birth weight. STDs and Pregnancy—CDC Fact Sheet; http://www.cdc.gov/std/pregnancy/STDFact-Pregnancy.htm.
Early births, 60 percent more common in black women: National Vital Statistics Report, Births: Final Data for 2010.
infant mortality rate in the United States among blacks remains twice as high as among whites: National Vital Statistics Report, Deaths: Final Data for 2010 61, no. 4 (May 2013); http://www.cdc.gov/nchs/data/nvsr/nvsr61/nvsr61_04.pdf.
What is known about genetic predispositions: See Danielle Dick and Arpana Agrawal, The Genetics of Alcohol and Other Drug Dependence, Alcohol Research and Health 2008; 31 (2):111–118.
3: CHARITY CARE
body mass index far above what my pocket guide listed as ideal: Body mass index (BMI) is a number calculated based on a person’s height and weight that is used in adults to identify those with weight problems. A BMI above 25 is regarded as overweight; a BMI over 30 is considered obese. Pearl’s BMI was 36.
handful have become famous: Bellevue Hospital Center is the oldest public hospital in the country (founded in 1736) and is probably best known for its psychiatric facilities. Cook County Hospital was featured in the 1993 blockbuster movie The Fugitive and was the inspiration for the equally popular 1994–2009 medical drama ER. I describe Grady hospital’s history in chapter 4.
Public hospitals began to decline: For a concise overview of the history of public hospitals, see Howard Waitzkin, Commentary—The History and Contradictions of the Health Care Safety Net, Health Services Research 2005; 40 (3):941–952.
Combined with other fiscal factors: In addition to Medicare and Medicaid passage, rising health care costs and local fiscal crises have been implicated in public hospital contractions and closures. Ibid.
Between 1987 and 1998 … the number of insured rose from 32 million to 44 million: See Michael Gusmano, Gerry Fairbrother, and Heidi Park, Exploring the Limits of the Safety Net: Community Health Centers and Care for the Uninsured, Health Affairs 2002; 21 (6):188–194.
One national study: Christopher Forrest and Ellen-Marie Whelan, Primary Care Safety-Net Delivery Sites in the United States: A Comparison of Community Health Centers, Hospital Outpatient Departments, and Physicians’ Offices, Journal of the American Medical Association, 2000; 284 (16):2077–2083.
Another study in rural Massachusetts: Sarah Kemble, Charity Care Programs: Part of the Solution or Part of the Problem? Public Health Reports 2000; 115 (5):419–429.
In recounting their respective outpatient experiences: For physician narratives on the disparities observed between public and private clinics, see David Ansell, County: Life, Death and Politics at Chicago’s Public Hospital (Chicago: Academy Chicago Publishers, 2011), and Fitzhugh Mullan, White Coat, Clenched Fist (New York: Macmillan, 1976).
echoed their sentiments: Neil Calman, Out of the Shadow: A White Inner-City Doctor Wrestles with Racial Prejudice, Health Affairs 2000; 19:170–174.
They were like characters: See Henry Louis Gates Jr., Colored People (New York: Vintage Books, 1994). A similar troubling pattern is observed in Lisa Cooper’s case study of a young black man with severe hypertension who states, “I don’t eat right. I don’t cook. I like McDonald’s, Burger King, Wendy’s, you name it.” See Lisa Cooper, A 41-Year-Old African American Man with Poorly Controlled Hypertension, Journal of the American Medical Association 2009; 301 (12):1260–1272.
she was slender in comparison: Tina’s body mass index (BMI) was 22, which fell within the recommended normal range (18.5–24.9). Pearl, in contrast, had a BMI of 36. All of the other women I saw that day also had BMI scores over 30, which would classify them as obese.
Not only are fibroids two to three times more common in black women: For a recent overview, see Heba Eltoukhi et al., The Health Disparities of Uterine Fibroid Tumors for African-American Women: A Public Health Issue, American Journal of Obstetrics and Gynecology 2014; 210 (3):194–199.
covers more than 50 million people: In 2000, Medicaid covered 46 million people during some portion of that year. These numbers steadily increased throughout the decade to a high point of 68 million in 2009. See https://www.ccwdata.org/web/guest/medicaid-charts.
Hypertension is the prototypical disease: For an overview of racial disparities with hypertension, see Robin Hertz et al., Racial Disparities in Hypertension Prevalence, Awareness, and Management, Archives of Internal Medicine 2005; 165 (18):2098–2104. See also David Martins et al., Hypertensive Chronic Kidney Disease in African Americans: Strategies for Improving Care, Cleveland Clinic Journal of Medicine 2012; 79 (10):726–734.
The reasons offered as to why black Americans suffer so severely from hypertension: For a brief summary of competing theories, see Flavio Fuchs, Why Do Black Americans Have Higher Prevalence of Hypertension? An Enigma Still Unsolved, Hypertension 2011; 57:379–380.
Armed with data from several research studies: The most influential one at the time was the publication of Dietary Approaches to Stop Hypertension (DASH) in which Laura Svetkey, a Duke professor of medicine, was one of the lead investigators. See Lawrence J. Appel et al., A Clinical Trial of the Effects of Dietary Patterns on Blood Pressure, New England Journal of Medicine 1997; 336:1117–1124.
Terms like glomerular filtration rate, thiazide diuretics, and calcium channel blockers: Glomerular filtration rate is a test used to assess how well the kidneys are working. Thiazide diuretics are a type of diuretic (also known as water pills) that puts more sodium and water into the urine to reduce bodily fluid volume and blood pressure. Calcium channel b
lockers are another type of medication that lowers blood pressure.
A 2005 New York Times article: Janny Scott, “Life at the Top in America Isn’t Just Better, It’s Longer,” New York Times, May 16, 2005.
A 2002 Institute of Medicine report: See Institute of Medicine, Care Without Coverage: Too Little, Too Late (Washington, D.C.: The National Academies Press, 2002).
A major 2001 study: David Baker et al., Lack of Health Insurance and Decline In Overall Health in Late Middle Age, New England Journal of Medicine 2001; 345:1106–1112.
nearly twice as likely as white Americans to live without health insurance: Marsha Lillie-Blanton and Catherine Hoffman, The Role of Health Insurance Coverage in Reducing Racial/Ethnic Disparities in Health Care, Health Affairs 2005; 24 (2):398–408.
A 2007 study found: J. Michael McWilliams et al., Health of Previously Uninsured Adults After Acquiring Medicare Coverage, Journal of the American Medical Association 2007; 298:2886–2894.
Tina was one of approximately forty million uninsured Americans: See U.S. Census Bureau, Health Insurance Coverage: 2000; http://www.census.gov/prod/2001pubs/p60-215.pdf. Since 2000, the number of uninsured Americans has consistently remained above 40 million. For data between the years 2007 and 2012, see the Henry J. Kaiser Family Foundation, Key Facts About the Uninsured Population: http://kff.org/uninsured/fact-sheet/key-facts-about-the-uninsured-population.
failed 1993 Clinton health plan: For an overview from a former insider on the subject, see Paul Starr, “What Happened to Health Care Reform,” The American Prospect, Winter 1995. See also Paul Starr, “The Hillarycare Mythology,” The American Prospect, September 2007.
I later learned that more than 70 percent of people: See the Henry J. Kaiser Family Foundation, The Uninsured: A Primer, October 2013; http://kff.org/report-section/the-uninsured-a-primer-2013-tables-and-data-notes.
4: INNER-CITY BLUES
not the classic findings of an acute heart attack requiring immediate cardiac catheterization or clot-busting drugs: The medical term for heart attack is myocardial infarction, or MI. One of the first steps in evaluating a patient with a suspected MI is to obtain an electrocardiogram (EKG). A waveform pattern known as ST-elevation MI, or STEMI, requires urgent restoration of blood flow. See Elliot Antman et al., ACC/AHA Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction—Executive Summary, Circulation 2004; 110:588–636.
watching TV medical dramas: ER, the critically and commercially successful TV series, was at its peak during the mid- to late 1990s. The show was popular among medical students, especially those at Harvard, where the show’s creator (Michael Crichton) and lead writer (Neal Baer) had attended. See Ellen Lerner Rothman, White Coat (New York: William Morrow and Company, 1999). Chicago Hope, created by prolific TV writer/producer David E. Kelley, also had a successful run during this period.
Duke did not have a training program in this field: Duke established an emergency medicine residency training program in 2002, two years after my graduation.
Extreme emotional distress, such as in response to an earthquake: On January 17, 1994, a major earthquake struck the Los Angeles area. On the day of the earthquake, researchers noted a sharp increase in the number of sudden cardiac deaths. See Jonathan Leor, W. Kenneth Poole, and Robert Kloner, Sudden Cardiac Death Triggered by an Earthquake, New England Journal of Medicine 1996; 334:413–419.
less dramatic but nonetheless mentally stressful scenarios could trigger cardiac events too: For the classic article on the subject, see Alan Rozanski et al., Mental Stress and the Induction of Silent Myocardial Ischemia in Patients with Coronary Artery Disease, New England Journal of Medicine 1988; 318:1005–1012. See also James Blumenthal et al., Mental Stress-Induced Ischemia in the Laboratory and Ambulatory Ischemia During Daily Life, Association and Hemodynamic features, Circulation 1995; 92:2102–2108.
rarely worked the way they did on TV medical dramas of the era: See Susan Diem, John Lantos, and James Tulsky, Cardiopulmonary Resuscitation on Television; Miracles and Misinformation, New England Journal of Medicine 1996; 334:1578–1582.
As physician Danielle Ofri writes: See Danielle Ofri, What Doctors Feel (Boston: Beacon Press, 2013).
Black women are more likely to die from heart disease: Adjusting for age, black women are about 1.4 times more likely to die from heart attacks than white women. Nearly 22 percent of deaths from heart disease in black women occurred before age 65; only about 8 percent of such deaths occurred in white women under 65. See Michele Casper et al., Women and Heart Disease; an Atlas of Racial and Ethnic Disparities in Mortality, Centers for Disease Control and Prevention, 2000; http://stacks.cdc.gov/view/cdc/12169/. See also American Heart Association, African Americans and Cardiovascular Diseases, Statistical Fact Sheet 2013 Update; http://www.heart.org/idc/groups/heart-public/@wcm/@sop/@smd/documents/downloadable/ucm_319568.pdf.
hypertension and diabetes are far more common: Hypertension is about 40 percent more common among blacks as compared to whites. In 2010, the prevalence of diabetes for adult blacks was nearly twice as much as for white adults. See High Blood Pressure Facts, Centers for Disease Control and Prevention, 2014; http://www.cdc.gov/bloodpressure/facts.htm. See also Minority Health, Black or African American Populations. Centers for Disease Control and Prevention, 2014; http://www.cdc.gov/minorityhealth/populations/REMP/black.html.
black women are almost twice as likely as white women to be obese: During 2006–2008, nearly 40 percent of black women were classified as obese in contrast to about 22 percent of white women. See Liping Pan et al., Differences in Prevalence of Obesity Among Black, White, Hispanic Adults, United States 2006–2008, Morbidity and Mortality Weekly Report 2009; 58 (27):740–744; http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5827a2.htm#tab1.
Grady was caught in the vortex of political and economic forces: For articles on the various troubles Grady experienced in the early 2000s, see “Portrait of an ER at the Breaking Point,” Newsweek, May 7, 2007; Shaila Dewan and Kevin Sack, “A Safety-Net Hospital Falls into Financial Crisis,” New York Times, January 8, 2008; Chris Megerian, “Night Falls on Grady,” The Emory Wheel, December 6, 2007; and “Three Part Series: The Past, Present, and Future of Grady Memorial Hospital,” Creative Loafing Atlanta, February 28, 2013, March 7, 2013, and March 14, 2013.
problems were evident: For example, A 2006 study ranked Grady near the bottom nationally in the treatment of heart failure and pneumonia. Hospital inspectors around this time reported broken medical equipment, sanitation issues, and poor recordkeeping that threatened the accreditation the hospital needed to participate in Medicare and Medicaid. In the emergency department, wait times routinely approached eight hours, sometimes longer. See the citations in the previous note for further details.
between 3,000 and 3,500 trauma victims: See Helen Kelley, Grady Hospital. Life and Death 24/7, M.D. News, Metro Atlanta Edition 5, no. 8 (August 2004).
I estimated that about 20 percent of the doctors were black: For an article examining the racial diversity within Emory University’s Department of Emergency Medicine, see Sheryl Heron and Leon Haley, Diversity in Emergency Medicine—A Model Program, Academic Emergency Medicine 2001; 8: 192–195. The authors state that when Emory’s program was started in 1975, all of the faculty and residents were white. By 2000, however, more than one-third of the faculty was black, and more than 20 percent of the residents were black.
For black male teens, homicide is the leading cause of death: See Arialdi Minino, Mortality Among Teenagers Aged 12–19 Years: United States, 1999–2006. National Center for Health Statistics Data Brief, No. 37, May 2010.
more than 90 percent of the time, young black homicide victims are killed by another black person: See Erika Harrell, Black Victims of Violent Crime, Bureau of Justice Statistics, August 2007; http://www.bjs.gov/content/pub/pdf/bvvc.pdf.
blacks make up more than 40 percent of inmates: See Heather West, Prison Inmates at Midyear 2009—Statistical Tables, U.S. Department of Justice, J
une 2010; http://www.bjs.gov/content/pub/pdf/pim09st.pdf.
talks often about his narrow escape from a life of crime: See Sampson Davis, Living and Dying in Brick City (New York: Spiegel & Grau, 2013).
Many black men face this dilemma: See Wes Moore, The Other West Moore (New York: Spiegel & Grau, 2010); Ben Carson, Gifted Hands (Grand Rapids: Zondervan, 1990); and Otis Brawley, How We Do Harm (New York: St. Martin’s Press, 2011).
we could let down our guard: The conversation that I had with Dr. Mason and Dr. Stephens is one of dozens I was part of in college, medical school, and law school. It underscores the tension between middle- and upper-class blacks and our poorer counterparts. This theme has been explored in the writings of several African American writers. See for example, Lawrence Otis Graham, Member of the Club (New York: Harper Collins, 1995); Sheryll Cashin, The Failures of Integration (New York: Public Affairs, 2004); and Eugene Robinson, Disintegration (New York: Doubleday, 2010).
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