Between 1995 and 1998, AIDS mortality in the United States dropped more than 60 percent: From 1981 to 1995, the estimated annual number of deaths among persons with AIDS increased from 451 to 50,628. By 1998, that number had dropped from 50,628 down to 18,851. See HIV Surveillance—United States—1981–2008, Morbidity and Mortality Weekly Report 2011; 60 (21):689–693.
reductions in death rates approaching 75 percent: See Robert S. Levine et al., Black-White Mortality from HIV in the United States Before and After Introduction of Highly Active Antiretroviral Therapy in 1996, American Journal of Public Health 2007; 97 (10):1884–1892.
black people accounted for a quarter of HIV cases during the first decade of the epidemic: See HIV and AIDS—United States 1981–2000. Morbidity and Mortality Weekly Report 2001; 50 (21):430–434.
In 1996, for the first time in the epidemic, more black people in America died of AIDS than whites: See Update: Trends in AIDS Incidence, Deaths, and Prevalence—United States, 1996, Morbidity and Mortality Weekly Report 1997; 46 (8):165–173.
the color of HIV/AIDS in the United States continued to darken: For a visual depiction of the statistical racial differences in HIV/AIDS, see HIV Surveillance by Race/Ethnicity, 2008–2011 data, National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention, Division of HIV/AIDS Prevention. Available at http://www.cdc.gov/hiv/pdf/statistics_surveillance_raceEthnicity.pdf.
that I started to fully appreciate the emotional weight of the diagnosis: For excellent physician narratives that explore the emotional impact (on both doctor and patient) of delivering a HIV diagnosis, see Abraham Verghese, My Own Country (New York: Simon and Schuster, 1994); Jerome Groopman, The Measure of Our Days (New York: Viking Penguin, 1997); and Daniel Ofri, Singular Intimacies (Boston: Beacon Press, 2003).
an indictment of one’s characters or morals: The controversial Pat Buchanan offered perhaps the most famous incendiary quote on the subject from the early years of the epidemic when he wrote in 1983: “The poor homosexuals—they have declared war upon nature, and now nature is exacting an awful retribution.” For this quote and other provocative statements, see “Pat Buchanan’s Greatest Hits,” Washington Post, February 4, 1987.
something I’d read and heard so much about: The term down-low became popular in the media during the late 1990s and early 2000s, widely covered in print and television. See for example, Benoit Denizet-Lewis, “Double Lives on the Down Low,” New York Times Magazine, August 3, 2003.
AIDS first became known to the medical community: For a comprehensive and engaging overview of the early history of the AIDS epidemic, see Randy Shilts, And the Band Played On (New York: St. Martin’s Press, 1987).
the Centers for Disease Control published a case report: This is the first reported description in the medical literature describing HIV/AIDS. See Pneumocystis Pneumonia—Los Angeles, Morbidity and Mortality Weekly Report 1981; 30:250–252.
article about forty-one gay men in New York and California: See Lawrence Altman, “Rare Cancer Seen in 41 Homosexuals,” New York Times, July 3, 1981.
the case of Ryan White: For a brief summary of his life, see Dirk Johnson, “Ryan White Dies of AIDS at 18; His Struggle Helped Pierce Myths,” New York Times, April 9, 1990.
the same way so many did back in the earliest days of HIV/AIDS: For graphic accounts of some of the flagrant discrimination directed toward patients with AIDS in the 1980s, see Randy Shilts, And the Band Played On, and Abraham Verghese, My Own Country.
the incidence of these AIDS-defining cancers has decreased greatly: See Meredith Shiels, Cancer Burden in the HIV-Infected Population in the United States, Journal of the National Cancer Institute 2011; 103:753–762.
Lung cancer is also more common in patients with HIV/AIDS: See for example, Jacques Cadranel et al., Lung Cancer in HIV Infected Patients: Facts, Questions and Challenges, Thorax 2006; 61 (11):1000–1008, and Deepthi Mani et al., Lung Cancer in HIV Infection, Clinical Lung Cancer 2012; 13(1):6–13.
documented the first two cases of AIDS in women in 1983: See Epidemiologic Notes and Reports. Immunodeficiency Among Female Sexual Partners of Males with Acquired Immune Deficiency Syndrome (AIDS)—New York, Morbidity and Mortality Weekly Report 1983; 31 (52):697–698.
most recent estimates place that number at more than 60 percent: For this and other data about black women and HIV infection, see HIV Surveillance by Race/Ethnicity, 2008–2011 data, National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention, Division of HIV/AIDS Prevention. Available at http://www.cdc.gov/hiv/pdf/statistics_surveillance_raceEthnicity.pdf. See also Women and HIV/AIDS in the United States, Henry J. Kaiser Family Foundation, March 6, 2014; http://kff.org/hivaids/fact-sheet/women-and-hivaids-in-the-united-states.
higher rates of other sexually transmitted diseases: The presence of other sexually transmitted infections increases the probability of both transmitting and acquiring HIV during sexual contact. For a brief summary, see http://www.cdc.gov/std/hiv/STDFact-STD-HIV.htm. Gonorrhea, chlamydia, and syphilis are all far more commonly seen in blacks than in whites, see, for example, http://www.cdc.gov/nchhstp/healthdisparities/AfricanAmericans.html.
has spoken at length about his experiences as a gay Harvard medical student in the 1980s: See Mark A. Schuster, On Being Gay in Medicine, Academic Pediatrics 2012; 12:75–78.
Chen recounted a similar version of medical antigay bias: See Pauline Chen, “Does Medicine Discourage Gay Doctors?” New York Times, April 26, 2012.
There is some data to support this contention: See Shelby Grad, “70% of African Americans Backed Prop. 8, Exit Poll Finds,” Los Angeles Times, November 5, 2008, and Changing Attitudes on Gay Marriage, The Pew Research Center’s Religion and Public Life Project, June 2013. For an editorial on the subject, see Bill Maxwell, “Homophobia: It’s a Black Thing,” Tampa Bay Times, June 17, 2011.
a handful of gay black celebrities have spoken on the issue: See, for example, Bill Carter, “Gay CNN Anchor Sees Risk in Book,” New York Times, May 15, 2011, and Cavan Sieczkowski, “Lee Daniels, Gay ‘Butler’ Director, Says ‘Black Men Can’t Come Out,’” Huffington Post, August 20, 2013.
blacks are the group least able to afford such attitudes: For data on the higher rates of HIV/AIDS among gay and bisexual black men, see http://www.cdc.gov/hiv/risk/racialethnic/bmsm/facts/. For a narrative discussion on the subject, see Donald G. McNeil Jr., “Poor Black and Hispanic Men Are the Face of HIV,” New York Times, December 5, 2013.
8: MATCHING
following a serious suicide attempt: One classic way (still taught today) of assessing the nature of a suicide attempt is to characterize it by the risk of death involved and the likelihood that someone can intervene to prevent the suicide. For example, a person who waits until their spouse is gone for the weekend before taking 100 sleeping pills and using a butcher knife to cut their wrist would generally be regarded as having made a high-risk, low-rescue attempt. In contrast, a person who takes a half-dozen aspirin tablets and uses a plastic knife to scratch their wrist directly in front of their spouse would be considered to have made a low-risk, high-rescue attempt. See Avery Weisman and J. William Worden, Risk-Rescue Rating in Suicide Assessment, Archives of General Psychiatry 1972; 26 (6):553–560.
modernized in requiring a bar-coded ID badge rather than a clunky key to come and go: Psychiatric units where people can be brought and kept against their wishes (i.e., involuntarily) are, by nature, locked to keep patients from walking out. Several workrooms and treatment rooms on each unit are also locked. In the older psychiatric hospitals where I have worked (both public and private), different units within the hospital required different keys, resulting in my having to carry five or six extra keys. Many times, I would get the keys confused and waste countless minutes.
Haldol was given in a dose of 5 milligrams, while Ativan was given in 2-milligram doses: Haldol (haloperidol) is an antipsychotic medication used to treat the active psychotic symptoms of schizophrenia. Ativan (lorazepam) is a sedative medication
commonly used to treat anxiety. The combination, particularly when injected, typically causes a rapid tranquilizing effect. A study done from my years in training declared this combination “the treatment of choice for acute psychotic agitation.” See John Battaglia et al., Haloperiodol, Lorazepam, or Both for Psychotic Agitation? American Journal of Emergency Medicine 1997; 15 (4):335–340. A more recent review indicated potential side effects with this treatment approach and the need for further research into this field of study. See Melanie Powney et al., Haloperidol for Psychosis-Induced Aggression or Agitation, The Cochrane database of systematic reviews 2012; http://www.ncbi.nlm.nih.gov/pubmed/23152276.
He even allowed Suzanne to observe him for “cheeking”: I’m not aware of data on this subject, but “cheeking” is a known occurrence in psychiatric hospitals and prisons. See, for example, Paul von Zielbauer, “Inmates Discarding Medicine Pose Problem,” New York Times, October 27, 2003.
Just 3 percent of all psychiatrists in America at the time were black: See Jeanne Miranda et al., Mental Health in the Context of Health Disparities, American Journal of Psychiatry 2008, 165 (9):1102–1108. This article reported that while black people comprised about 13 percent of the U.S. population, they made up 3 percent of psychiatrists, 2 percent of psychologists, and 4 percent of social workers.
Durham had a population more than 40 percent black: In 2000, Durham’s population was 43.5 percent black. In 2010, it was 41 percent black. See http://censusviewer.com/city/NC/Durham.
By the mid-1970s, the proportion of black medical students had nearly tripled: In the 1968–1969 academic year, 266 black students enrolled in U.S. medical schools, comprising 2.7 percent of national totals. By 1974–1975, that number had increased to 1,106 black students, or 7.5 percent of the total number. See Association of American Medical Colleges, Diversity in Medical Education: Facts and Figures 2012, Diversity Policy and Programs, Fall 2012; www.aamc.org/publications.
The first main challenge to this new order: Regents of the University of California v. Bakke, 438 U.S. 265, 1978. See note Although they ultimately graduated at similar rates for further background on this case.
federal appeals court ruling that struck down race-based affirmative action programs: Hopwood v. Texas, 78 F. 3d 932 (5th Cir. 1996). For a left-leaning slant on this decision and the similar University of California Regents ban on racial preferences, see Peter Applebome, “Affirmative Action Ban Changes a Law School,” New York Times, July 2, 1997. For a right-leaning view, see Terence J. Pell, “Texas Must Choose Between a Court Order and a Clinton Edict,” Wall Street Journal, April 2, 1997.
They found that black doctors served black patients at six times the rate as other physicians: See, for example, Miriam Komaromy et al., The Role of Black and Hispanic Physicians in Providing Health Care for Underserved Populations, New England Journal of Medicine 1996; 334:1305–1310. The authors explicitly discuss the political concerns of the era, noting: “These issues are particularly timely because affirmative-action programs were recently abolished in the California state university system and affirmative-action policies have become a prominent political issue.”
a related group of studies found that black patients tended to have more positive interactions with black physicians: These studies found that black patients were more likely to rate black physicians as excellent and to describe feeling that their preventive care and other health needs had been met. Another study reported that same-race appointments were longer in duration and rated by black patients as more satisfying. See Somnath Saha et al., Patient-Physician Racial Concordance and the Perceived Quality and Use of Health Care, Archives of Internal Medicine 1999; 159:997–1004; Lisa Cooper et al., Patient-Centered Communication, Ratings of Care, and Concordance of Patient and Physician Race, Annals of Internal Medicine 2003; 139:907–915; and Lisa Cooper-Patrick et al., Race, Gender, and Partnership in the Patient-Physician Relationship, Journal of the American Medical Association 1999; 282:583–589.
a position advocated by leading mainstream medical organizations: For position statements from the American College of Physicians, Institute of Medicine, and Association of American Medical Colleges on affirmative action and the care of minority patients, see Racial and Ethnic Disparities in Health Care: A Position Paper of the American College of Physicians, Annals of Internal Medicine 2004; 141:226–232; Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, Institute of Medicine, 2002; and Jordan Cohen, The Consequences of Premature Abandonment of Affirmative Action in Medical School Admissions, Journal of the American Medical Association 2003: 289 (9):1143–1149.
Some of the research in this area has shown no additional benefits to black patients: For example, a 2008 paper investigated the care of depressed patients in primary care settings and concluded that black physicians were no more likely than white physicians to discuss depression symptoms with black patients; see Bri Ghods et al., Patient-Physician Communication in the Primary Care Visits of African-Americans and Whites with Depression, Journal of General Internal Medicine, 2008; 23:600–606. Another study observed that black patient-doctor encounters did not result in improved rates of lifestyle counseling for obese patients; see Sara Bleich, Impact of Patient-Doctor Race Concordance on Rates of Weight-Related Counseling in Visits by Black and White Obese Individuals, Obesity (Silver Spring) 2012; 20:562–570. These authors speculated that in some instances, other factors, such as physician gender, patient socioeconomic status, and patient cultural beliefs and patterns, might have greater influence on the patient-doctor dynamic than race alone.
while critics have argued that several influential studies were either methodologically flawed or overstated their conclusions: For a broader critique of the rationale that black doctors confer greater benefits to black patients, see Jonathan Glick and Sally Satel, The Health Disparities Myth: Diagnosing the Treatment Gap (Washington, D.C.: American Enterprise Institute for Public Policy Research, 2006).
There have even been some reports that hint at the possibility that black doctors, for a variety of reasons, might deliver a lower quality of care: In 2004, Peter Bach of the Memorial Sloan-Kettering Cancer Center looked at primary care visits by black and white Medicare beneficiaries. In exploring the well-established principle that black patients generally receive lower-quality health care than white patients, they found that black patients and white patients in their study were to a large extent treated by different physicians. Nearly a quarter of the black patients in the study saw black physicians, some of whom were part of the larger physician group that was less likely to be board certified and more likely to report facing difficulties getting their patients high-quality specialty referrals, high-quality diagnostic imaging, and nonemergency hospital admission. To be clear, Bach and colleagues do not in any way state or imply that black physicians might be delivering a lower quality of care (for whatever reason), nor was their study designed to evaluate this specific issue. See Peter Bach et al., Primary Care Physicians Who Treat Blacks and Whites, New England Journal of Medicine 2004; 351:575–584.
For a more direct look at some of the problems faced by graduates of historically black medical schools, see Andrew Julian and Jack Dolan, “Historically Black Medical Schools Struggle to Compete for Dollars, Students,” Hartford Courant, June 30, 2003. This article reported that graduates of Howard and Meharry face substantially higher disciplinary actions by state medical boards than most other schools. Among the potential causes proffered: institutional financial problems that compromise the quality of education; difficulty attracting quality black students due to more aggressive recruitment from more prestigious, predominately white schools; a patient population that is much sicker and more difficult to treat; and possible racism of state disciplinary boards toward black doctors. For an article emphasizing that minority doctors are more likely to care for sicker patients, see Ernest Moy and Barbara Bartman, Physician Race and Care of Minority and Medically Indigent Patients, Journal of the American Medical Association 1995
; 273:1515–1520.
International medical graduates (IMGs) constitute about 25 percent of American doctors: This is based on 2006 data. For a brief overview of recent trends with IMG physicians, see http://www.ama-assn.org/ama/pub/about-ama/our-people/member-groups-sections/international-medical-graduates/imgs-in-united-states.page?.
In a 2005 essay: See Alok Khorana, Concordance, Health Affairs March/April 2005; 24 (2) 511–515.
9: DOING THE RIGHT THING
a mixture of schizophrenia and bipolar disorder in his case: Schizophrenia is characterized by a variety of impairing symptoms such as delusional beliefs, auditory hallucinations (hearing voices), and distorted thought, speech, and behavior patterns. Bipolar disorder (also known as manic-depression) is characterized by distinct episodes of depression and mania (or hypomania), the latter involving periods of euphoria, excessive energy, less need for sleep, excessive risk-taking, and impaired judgment, among other symptoms. Individuals with schizoaffective disorder can exhibit features from both disorders.
made him tired all the time and made his muscles too stiff: Fatigue is a common side effect of many, if not most, antipsychotic medications. The older antipsychotics (called typical or first-generation) can cause muscle stiffness through their blockage of dopamine receptors, sometimes causing symptoms similar to what is seen in Parkinson’s disease.
The only problem was that it caused him to gain weight: The newer antipsychotic medications (called atypical or second-generation) are, with a few exceptions, highly associated with weight gain.
estimated that behavioral choices account for at least 900,000 deaths each year: See J. Michael McGinnis et al., The Case for More Active Policy Attention to Health Promotion, Health Affairs March/April 2002; 21(2):78–93.
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