For Doctors of Color, Microaggressions Are All Too Familiar

Of note:

When Dr. Onyeka Otugo was doing her training in emergency medicine, in Cleveland and Chicago, she was often mistaken for a janitor or food services worker even after introducing herself as a doctor. She realized early on that her white male counterparts were not experiencing similar mix-ups.

“People ask me several times if the doctor is coming in, which can be frustrating,” said Dr. Otugo, who is now an emergency medicine attending physician and health policy fellow at Brigham and Women’s Hospital in Boston. “They ask you if you’re coming in to take the trash out — stuff they wouldn’t ask a physician who was a white male.”

After years of training in predominantly white emergency departments, Dr. Otugo has experienced many such microaggressions. The term, coined in the 1970s by Dr. Chester Pierce, a psychiatrist, refers to “subtle, stunning, often automatic, and nonverbal exchanges which are ‘put downs’” of Black people and members of other minority groups; “micro” refers to their routine frequency, not the scale of their impact. Dr. Otugo said the encounters sometimes made her wonder whether she was a qualified and competent medical practitioner, because others did not see her that way.

Other Black women doctors, across specialties, said that such experiences were all too common. Dr. Kimberly Manning, an internal medicine doctor at Grady Memorial Hospital in Atlanta, recalled countless microaggressions in clinical settings. “People might not realize you’re offended, but it’s like death by a thousand paper cuts,” Dr. Manning said. “It can cause you to shrink.”

The field of medicine has long skewed white and male. Only 5 percent of the American physician work force is African-American, and roughly 2 percent are Black women. Emergency medicine is even more predominantly white, with just 3 percent of physicians identifying as Black. The pipeline is also part of the problem; at American medical schools, just 7 percent of the student populationis now Black.

But for Black female physicians, making it into the field is only the first of many challenges. More than a dozen Black women interviewed said that they frequently heard comments from colleagues and patients questioning their credibility and undermining their authority while on the job. These experiences damaged their sense of confidence and sometimes hampered teamwork, they said, creating tensions that cost precious time during emergency procedures.

Some physicians said they found the microaggressions particularly frustrating knowing that, as Black doctors, they brought an invaluable perspective to the care they offer. A 2018 study showed that Black patients had improved outcomes when seen by Black doctors, and were more likely to agree to preventive care measures like diabetes screenings and cholesterol tests.

In May, four female physicians of color published a paper in Annals of Emergency Medicine on microaggressions. The authors, Dr. Melanie Molina, Dr. Adaira Landry, Dr. Anita Chary and Dr. Sherri-Ann Burnett-Bowie, said they hoped that, by shining a spotlight on the problem, they might reduce the sense of isolation that Black female physicians experience and compel their white colleagues to take specific steps toward eliminating conscious and unconscious bias.

Discussions about lack of diversity in medicine resurfaced in early August, when the Journal of the American Heart Association retracted a paper that argued against affirmative action initiatives in the field and said that Black and Hispanic trainees were less qualified than their white and Asian counterparts.

Dr. Phindile Chowa, 33, an assistant professor of emergency medicine at Emory University, was in her second year of an emergency-medicine residency when an attending in her department mistook her for an electrocardiogram technician, even though she had previously worked with him on rotations. She approached him to give a report on her patients, and he wordlessly put out his hand, expecting her to hand over an electrocardiogram scan.

“He never apologized,” Dr. Chowa said. “He did not think he did a single thing wrong that day. I was the only Black resident in my class. How could he not know who I am?”

The derogatory encounters continued from there. Colleagues have referred to her as “sweetie” or “honey.” She recalled one patient who asked repeatedly who she was over the course of a hospital visit, while quickly learning the name of her white male attending physician. When she was first admitted to her residency, at Harvard, a medical school classmate suggested that she had had an “edge” in the selection process because of her race.

Such comments can create an environment of fear for Black women. Dr. Otugo recalled overhearing her Black female colleagues in Chicago discuss how they were going to style their hair for their clerkships. Many of them worried that if they wore their hair naturally, instead of straightening it or even changing it to lighter colors, their grades and performance evaluations from white physicians might suffer.

Dr. Sheryl Heron, a Black professor of emergency medicine at Emory University School of Medicine, who has worked in the field for more than two decades, said microaggressions can exact a long-lasting toll. “After the twelve-thousandth time, it starts to impede your ability to be successful,” she said. “You start to go into scenarios about your self-worth. It’s a head trip.”

This comes on top of the stresses that are already pervasive in emergency departments. A 2018 survey of more than 1,500 early-career doctors in emergency medicine found that 76 percent were experiencing symptoms of burnout.

But Black women doctors said they have seen how Black patients rely on their presence to get the best care. Monique Smith, a physician in Oakland, Calif., was working in the emergency room one night when a young Black man came in with injuries from a car accident. She was confused when some of her colleagues called him a “troublemaker,” so she visited the patient’s bed and asked him about his experience being admitted. He told her that he had begun to lash out when he felt he was being stereotyped by staff members because of his skin color and the neighborhood he came from.

“I was able to go into the room and say, ‘Hey dude, Black person to Black person, what’s up?’” Dr. Smith said. “Then I advocated for him and made sure he got streamlined care.”

The conversation made Dr. Smith more attuned to the degrading comments that Black patients experience at hospitals, and she now tries to intervene and identify her colleagues’ biases. She believes, for example, that physicians are sometimes quicker to order drug testing for Black patients, even if their symptoms are most likely unrelated to substance abuse.

But many Black physicians find it challenging to be advocates for themselves and their patients, particularly within the rigid hierarchies of the medical system. “You’re faced with situations where you’re going to be perceived as the angry Black woman even though you’re just being your own advocate,” said Dr. Katrina Gipson, an emergency medicine physician. “You’re constantly walking the line of how to be a consummate professional.”

Dr. Landry, an author of the recent paper and an emergency medicine physician at Brigham and Women’s Hospital, said that hospital and residency directors who are looking to address the deep-rooted problem should begin with hearing and validating the personal experiences of Black doctors. Continuing to diversify emergency medicine departments is also critical, she added, so that Black physicians are not working in isolation to implement cultural changes and arrange mentorship from more senior Black colleagues.

“I’m the only African-American female physician faculty member in my department, and that creates this feeling of not having a support system to speak up when something happens to you,” Dr. Landry said. “Having this paper is a validating tool for people to say, ‘See, I’m not the only one this is happening to.’”

Dr. Molina, an emergency medicine resident at Brigham and Women’s Hospital and one of the paper’s authors, said that spotlighting diversity in medicine was particularly important amid a pandemic that disproportionately impacts Black patients. “The Covid pandemic has served to emphasize health disparities and how they impact Black populations,” she said. “As emergency physicians, we have to present a united front recognizing racism is a public health issue.”

 

ICYMI: Black Children Are More Likely to Die After Surgery Than White Peers, Study Shows

Yet another study showing racial disparities in healthcare:

Black children are more than three times as likely to die within a month of surgery as white children, according to a study published in the journal Pediatrics on Monday.

Disparities in surgical outcomes between Black and white patients have been well established, with researchers attributing some of the difference to higher rates of chronic conditions among Black people. But this study, which looked at data on 172,549 children, highlights the racial disparities in health outcomes even when comparing healthy children.

Researchers found that Black children were 3.4 times as likely to die within a month after surgery and were 1.2 times as likely to develop postoperative complications. The authors performed a retrospective study based on data on children who underwent surgery from 2012 through 2017.

Olubukola Nafiu, the lead author of the study and a pediatric anesthesiologist at Nationwide Children’s Hospital in Columbus, Ohio, said the authors were not surprised to find that healthy children, across the board, had extremely low rates of mortality and rates of complications after surgery. But what surprised them was the magnitude of the difference in mortality and complication rates by race.

“The hypothesis we had when we started was that if you studied a relatively healthy cohort of patients, there shouldn’t be any difference in outcomes,” Dr. Nafiu said.

The authors, in their paper, acknowledged limitations of the study: They did not explore the site of care where patients received their treatments or the insurance status of patients, which can be used as a proxy for socioeconomic status. This meant they could not account for differences in the quality of care that patients received or the economic backgrounds of the patients.

Another limitation was that because mortality and postoperative complications are so uncommon among healthy children, it is possible that most of the cases came from a few hospitals, Dr. Nafiu said.

But while Black people are more likely to receive care in low-performing hospitals, that may not be the main factor driving the gap this study found, Dr. Nafiu said. The hospitals examined in the study were all part of the National Surgical Quality Improvement Program, a voluntary program, meaning they had the resources to be part of the program and the belief that quality improvement is important.

Adil Haider, dean of the medical college at Aga Khan University, who was not involved with the study, said that it told a key piece of the story about racial disparities in surgical outcomes, but that there were still many questions about what drives disparities.

Brain Waste among U.S. Immigrants with Health Degrees: A Multi-State Profile

Good in depth study by MPI. Suspect similar patterns in Canada:

The coronavirus pandemic that swept into communities across the United States beginning in Spring 2020 has placed enormous strain on health-care systems and highlighted the work of both U.S.- and foreign-born health professionals. But even as the need for testing, treatment, and care is high, an estimated 263,000 immigrants and refugees with at least a four-year degree in a health field have largely been sidelined, either employed in jobs that require no more than a high school diploma or out of work.

U.S. and State Data

This spreadsheet offers estimates of immigrants and refugees with health-related undergraduate degrees who are underemployed or unemployed, both nationwide and in selected states. It includes details on their race/ethnicity, legal status, degree majors, origin countries, and the languages other than English that they speak. Click here.

This fact sheet offers the first state-level profile of this untapped pool of immigrant health professionals. Using data from the U.S. Census Bureau and U.S. Department of Labor, it provides estimates of the number and key characteristics of underutilized immigrants with health degrees, including their English proficiency, the other languages they speak, their top fields of study, and the legal statuses they hold.

Among the key findings of this analysis are that these immigrants are widely distributed across the United States, not concentrated in traditional immigrant-gateway states. There is also considerable overlap between the languages other than English that they speak and those spoken by Limited English Proficient populations in the states where they live, making them a potentially valuable resource in providing linguistically and culturally competent care.

Source: https://www.migrationpolicy.org/research/brain-waste-immigrants-health-degrees-multi-state-profile

Immigrant Health-Care Workers in the United States

Another good analysis by MPI. Similar picture in Canada with respect to immigrants and visible minorities:

Immigrants represent disproportionately high shares of U.S. workers in many essential occupations, including in health care—a fact underscored during the coronavirus pandemic as the foreign born have played a significant role in frontline pandemic-response sectors. In 2018, more than 2.6 million immigrants, including 314,000 refugees, were employed as health-care workers, with 1.5 million of them working as doctors, registered nurses, and pharmacists. Immigrants are overrepresented among certain health-care occupations. Even as immigrants represent 17 percent of the overall U.S. civilian workforce, they are 28 percent of physicians and 24 percent of dentists, for example, as well as 38 percent of home health aides.

Overall, immigrants ranging from naturalized citizens, legal permanent residents, and temporary workers to recipients of Temporary Protected Status (TPS) and the Deferred Action for Childhood Arrivals (DACA) program accounted for nearly 18 percent of the 14.7 million people in the United States working in a health-care occupation in 2018. As a group, immigrant health-care workers are more likely than their U.S.-born counterparts to have obtained a university-level education. Immigrant women in the industry were more likely than natives to work in direct health-care support, the occupations known for low wages. In contrast, immigrant men were more likely than the U.S. born to be physicians and surgeons, occupations that are well compensated. Compared to all foreign-born workers, those employed in the health-care field were more likely to speak English fluently and had higher rates of naturalization and health insurance coverage.

Definitions

The term “foreign born” refers to people residing in the United States at the time of the Census survey who were not U.S. citizens at birth. The foreign-born population includes naturalized citizens, lawful permanent residents (LPRs, also known as green-card holders), refugees and asylees, legal nonimmigrants (including those on student, work, or certain other temporary visas), and persons residing in the country without authorization. The terms “immigrant” and “foreign born” are used here interchangeably.

The terms “U.S. born” and “native born” are used interchangeably and refer to persons with U.S. citizenship at birth, including persons born in Puerto Rico or abroad born to a U.S.-citizen parent.

Most analyses in this article divide health-care occupations into the following occupational groups:

Health-Care Practitioners and Technical Occupations

  • Physicians and surgeons
  • Therapists (i.e., occupational therapists, physical therapists, respiratory therapists, and speech-language pathologists)
  • Registered nurses (RNs)
  • Health-care technologists and technicians (i.e., clinical laboratory technologists and technicians, dental hygienists, emergency medical technicians and paramedics, licensed practical and licensed vocational nurses, pharmacy technicians, and radiologic technologists and technicians)
  • Health practitioners and technical occupations, all others (i.e., dentists, nurse practitioners and nurse midwives, optometrists, pharmacists, physician assistants, podiatrists, and veterinarians

Health-Care Support Occupations

  • Home health aides
  • Personal care aides
  • Nursing assistants
  • Health-care support, all others (i.e., dental assistants, massage therapists, medical assistants, phlebotomists, and physical therapist assistants and aides).

As the Migration Policy Institute (MPI) has documented, significant numbers of immigrant college graduates with health-related degrees are facing skill underutilization, in other words are working in low-skilled jobs (for example registered nurses working as health aides) or are out of work. This skill underutilization, often referred to as brain waste, affects 263,000 immigrants in the United States with college degrees—a workforce whose talents could be tapped amid the pandemic.

Even before the COVID-19 pandemic, a number of health-care occupations were among the fastest-growing occupations, as projected by the U.S. Bureau of Labor Statistics (BLS) for the 2018-28 period. The more immediate trends now are less clear. Like other parts of the U.S. economy, the health-care sector has suffered job losses since February 2020, which may continue until the economy rebalances. Nonetheless, the main drivers for a greater demand for health-care services—population aging and longevity—remain valid. As in the past, immigrants can be expected to play a significant role in the future of U.S. health care.

This Spotlight provides a demographic and socioeconomic profile of foreign-born health-care workers residing in the United States. The data come primarily from the U.S. Census Bureau’s 2018 American Community Survey (ACS) and BLS. All data refer to civilian, employed workers ages 16 and older, unless otherwise noted.

Source: Immigrant Health-Care Workers in the United States

As U.S. Health-Care System Buckles under Pandemic, Immigrant & Refugee Professionals Could Represent a Critical Resource

Another good analysis by MPI:

In this time of crisis when health-care workers are not only on the frontlines of fighting COVID-19 but are themselves among its primary targets, it is more essential than ever to have enough qualified professionals to meet the needs of a buckling U.S. medical system. As governors call retired physicians back into service and medical schools graduate students on an accelerated basis, another pool can be tapped: Immigrant and refugee physicians, nurses, and health-care technicians who could offer not only critical professional knowledge but also essential linguistic and cultural skills. Around the globe, a number of countries battling the virus (among them France, Colombia, Spain, Chile, and Ireland) and subnational governments (including New York State, California, New Jersey, and the province of Buenos Aires in Argentina) are actively seeking ways to engage this population.

There are 1.5 million immigrants already employed in the U.S. health-care system as doctors, registered nurses, and pharmacists. At the same time, Migration Policy Institute (MPI) analysis finds another 263,000 immigrants and refugees with undergraduate degrees in health-related fields are either relegated to low-paying jobs that require significantly less education or are out of work. Along with 846,000 U.S.-born adults whose health-related college degrees are similarly underutilized—a phenomenon MPI has long referred to as “brain waste”— these immigrants represent a potentially important source of staff for the U.S. health corps. And because these immigrants tend to be younger than their U.S.-born counterparts, they represent an important pool of responders to a disease that is particularly dangerous for those 60 and older.

Figure 1. Adults (ages 25 to 64) Whose Health-Related Undergraduate Degrees Are Not Fully Utilized, by Nativity and Place of Education, 2017

Source: Migration Policy Institute (MPI) tabulation of U.S. Census Bureau 2017 American Community Survey (ACS) data.

Definitions & Methodological Note

Underutilized adults are defined here as civilians between ages 25 and 64 who currently are employed in jobs that require no more than a high school diploma, are unemployed, or are not engaged in the labor force.

Immigrants refers to persons who were not U.S. citizens at birth. This population includes naturalized U.S. citizens, lawful permanent immigrants (or green-card holders), refugees and asylees, certain legal nonimmigrants (including those on student, work, or other temporary visas), and persons residing in the country without authorization. The term U.S. born refers to those born in the United States or abroad to at least one U.S.-citizen parent.

Foreign trained are defined here as immigrants who came to the United States at age 25 or later and who have at least a bachelor’s degree (i.e., they likely obtained their degrees abroad), while U.S. trained are those who arrived before age 25 and obtained their four-year college degrees in the United States.

Methodological note: The analysis here differs from the Migration Policy Institute’s earlier work on immigrant skill underutilization (also known as brain waste), in that for the purposes of examining an urgently needed talent pool that could be tapped during this crisis, it also includes college-educated immigrants of prime working age who not engaged in the labor force. Foreign-trained health-care graduates are significantly more likely to be out of the labor force than their U.S.-trained immigrant counterparts and could thus represent a substantial potential pool of workers. This analysis finds 140,000 immigrants with health-related degrees ages 25-64 are not employed and not looking for work, representing 53 percent of all 263,000 immigrants with a four-year health-care degree who are underutilized. Forty percent are employed in jobs requiring no more than a high school degree, and the remaining 7 percent are unemployed.

MPI research over the years has shown that a sizeable share of immigrant college graduates faces significant challenges in securing jobs that take full advantage of their prior education and work experience. The analyses presented here affirm that this underutilization is common among the foreign born who hold undergraduate degrees in the health-care field. What, then, are some of the most policy relevant characteristics of this population?

Place of Education

Where immigrants receive their education matters. Almost two-thirds (or 165,000) of all underutilized health-care immigrant workers likely obtained their health-related education outside the United States. The underemployment of these health-care professionals is in some ways not surprising: employers may be reluctant to hire workers with degrees from universities that are unfamiliar to them. Also, immigrants may lack important professional networks that connect them to employment opportunities or a sufficient level of professional English competence to get promoted. Further, their credentials may not be aligned with those required by U.S. health-care systems and licensing authorities. And it is common knowledge that obtaining U.S. licenses to work is difficult, time-consuming, and costly.

Demographics

As with health-care workers overall, college-educated immigrant and U.S.-born workers stuck in jobs requiring no more than a high school degree or out of work are overwhelmingly female (roughly 80 percent). They differ, though, in their age distribution—one factor that may be important in combatting a disease that is particularly dangerous for older persons. These immigrants tend to be younger than their U.S.-born counterparts: 56 percent are between ages 25 and 44, versus 45 percent among U.S.-born underutilized health professionals.

These immigrants also have long years of U.S. residence, with 62 percent having been in the United States for more than a decade. On the one hand, many may have gained or improved their English proficiency and acquired U.S. work experience. On the other hand, many may have been outside the health-care field for years, and their skills and education may have atrophied.

Degree Field

Nursing is the most common degree held by underutilized immigrants and refugees. Approximately 118,000 immigrants with undergraduate degrees in nursing are underutilized, representing 45 percent of all immigrant-health care professionals working below their skill level or sidelined. The data analyzed here indicate that many are working in low-paying jobs such as nursing assistants, home health aides, personal care aides, or as domestic help. Another 10 percent received undergraduate degrees in pharmacy and pharmaceutical sciences, followed by 8 percent with treatment therapy and 5 percent with medical technology technician degrees.

Language Skills

Underutilized immigrant health-care professionals could provide an important linguistic and cultural resource for their own communities now, during this time of crisis, and in the future. More than two-thirds are English proficient, that is, they speak English very well or only English. They also speak a variety of languages other than English, including Spanish (17 percent), Tagalog (15 percent), Chinese (6 percent), Korean and Arabic (4 percent each), as well as Haitian, Russian, Vietnamese, Hindi, Portuguese, French, and Telugu (2 percent each).

States of Residence

State Estimates of Health-Care Professional Underutilization

Find estimates of the size of the population of health-care professionals, immigrant and U.S. born alike, experiencing skill underutilization, as well as their place of education, for the top 20 states. Click here for the data.

More than 60 percent of underutilized immigrant health-care professionals live in traditional immigrant-receiving states. California has, by far, the largest number of such workers: 24 percent of the national total, or 60,000 workers. Other top states: Florida, 11 percent (or 29,000); Texas, 9 percent (23,000), New York, 8 percent (22,000), New Jersey, 5 percent (14,000), and Illinois, 4 percent (11,000).

Figure 2. Immigrant Adults (ages 25 to 64) Whose Health-Related Undergraduate Degrees Are Not Fully Utilized, by State of Residence, 2017

Source: MPI tabulation of Census Bureau 2017 ACS data.

Tapping This Talent?

Even before the COVID-19 pandemic, the skills of 263,000 immigrants and refugees with college degrees in health-related fields had not been put to the best use in the U.S. labor market. However, in a time of crisis with growing shortages of staff in hospitals, community clinics, health departments, and testing centers, many of these immigrants could be mobilized and re-employed in jobs across the health-care field.

While state governments and medical systems must remain vigilant about the quality of health-care services their residents receive, some opportunities to make adjustments to the arduous licensing process exist. States could speed up the certification process by allowing immigrant health-care professionals who pass all requirements except the final exam to work under supervision, or they could extend short-term, provisional approval for a limited set of tasks. The data presented here indicate that workers with nursing training could represent a promising target group. These nurses could be employed in assisting with testing for the virus. At minimum, these immigrant health-care professionals could be engaged in providing language and cultural assistance to overburdened health systems and frightened patients alike.

As hospital emergency rooms, community health centers, and other medical offices reel from the tremendous strain that the COVID-19 pandemic has brought, immigrant health-care professionals whose skills have not been fully utilized represent a promising candidate pool for policymakers, licensing authorities, and health-care providers to tap in a moment of national crisis.

Source: www.migrationpolicy.org/news/us-health-care-system-coronavirus-immigrant-professionals-untapped-resource

Portugal gives migrants and asylum-seekers full citizenship rights during coronavirus outbreak

Of note. Best approach from a public health perspective (not full rights, can’t vote):

Portugal has temporarily given all migrants and asylum seekers full citizenship rights, granting them full access to the country’s healthcare as the outbreak of the novel coronavirusescalates in the country.

The move will “unequivocally guarantee the rights of all the foreign citizens” with applications pending with Portuguese immigration, meaning they are “in a situation of regular permanence in National Territory,” until June 30, the Portuguese Council of Ministers said on Friday.
The Portuguese Council of Ministers explained that the decision was taken to “reduce the risks for public health” of maintaining the current scheduling of appointments at the immigration office, for both the border agents and the migrants and asylum seekers.
Portugal declared a State of Emergency on March 18 that came into effect at midnight that day and was due to last for 15 days. Portuguese Prime Minister Antonio Costa said during a news conference that “democracy won’t be suspended.”
The country was a dictatorship for decades, with democracy being restored in 1974.
President Marcelo Rebelo de Sousa called the Covid-19 pandemic “a true war,” which would bring true challenges to the country’s “way of life and economy.”
Rebelo de Sousa also praised the behavior of Portuguese citizens, “who have been exemplary in imposing a self-quarantine,” reflecting “a country that has lived through everything.”
Portugal has has 6,408 cases of coronavirus, with 140 deaths and 43 recovered, according to figures from Johns Hopkins University.

Source: Portugal gives migrants and asylum-seekers full citizenship rights during coronavirus outbreak

The U.K. Needs Immigrants To Work In Its Health Service. The Chancellor Just Gave Them A Reason Not To Come.

Self-defeating move, it would appear:

Immigrants to the U.K. will have to pay more into the National Health Service, whether or not they use its services. By making it more expensive for migrants to come and work, this surcharge may in fact disincentivize the very workers the health service needs at a time of intense labor shortages.

Conservative Chancellor Rishi Sunak announced the increase while presenting his first budget to the U.K. House of Commons. Immigrants coming to the U.K. with a visa to work or join family for more than six months will now have to pay, alongside other fees, a surcharge of £624 for every year of their visa, an increase of more than 50% from where it was at £400, which was itself an increase from £200 in late 2018 (under the new system children will be charged a little less than adults, £470 per year). The funds from the surcharge go into the country’s National Health Service, or NHS.

The stated aim of the surcharge is to prevent migrants from burdening the NHS, as the Chancellor made clear in his speech to the commons: “Migrants benefit from our NHS. And we all want them to do so, but it’s right that what people get out, they also put in. There is a surcharge already, but it doesn’t properly reflect the benefits people receive.”

The specific amount of £624 appears linked to previous claims made by the Conservative party that migrants incur costs to the NHS of around £625 per year. The Guardian fact-checked this claim in 2019, and absent any source for the number, declared it unverifiable.

Nonetheless, the perception that migrants burden the NHS is a common one in post-Brexit Britain, with plenty of anecdotal stories of over-full waiting rooms and months-long waiting times. But research into the economic contributions of immigrants to the U.K., particularly those from the European Union (who will soon be subject to the NHS surcharge), suggests they are not the burden people think they are. A comprehensive review of EU immigrants’ contribution to the country’s public finances commissioned by the government in 2018 found that on average those migrants paid more into, and took less out of, the public purse than native Britons.

In any case, framing the issue as how much immigrants take out and put into the NHS is deceptive. Immigrants who work in the U.K. already contribute to the public finances by paying tax and contributing to national insurance, the country’s social security scheme. As the above-mentioned Guardian piece pointed out, immigrants already “pay for the NHS all year round”.

In this light, the NHS surcharge can be seen as double taxation, and it’s worth noting it will soon be extended to EU citizens, who make up a large proportion of the migrants coming to the U.K. Professor Jonathan Portes, senior fellow of the UK in a Changing Europe, said: “The overall impact of immigration on the NHS is positive, as the Government’s own Migration Advisory Committee concluded. Given that, it’s very hard to justify extending the double-charging that already applies to non-EU migrants to those from the EU.”

The surcharge may also work against the Chancellor’s stated intention of bolstering the NHS. By making it more expensive for workers to come, it could put off some of the people the NHS needs most.

For example, a qualified nurse wanting to come to the country under the Tier 2 skilled visa scheme could expect to pay £464 for the visa fee, and £1872 for three years’ worth of NHS surcharge. If they are coming with dependents, that’s an additional £1410 per child and £1872 for a spouse. According to the Royal College of Nursing, the average starting salary a qualified nurse coming to the country could expect to get is around £25,000, well below the national average salary for full-time work.

The issue is that nursing is one of the many NHS jobs that are currently on the U.K. government’s shortage occupation list. That is to say, it’s one of those jobs the U.K. desperately needs people for to prop up its health service. By increasing the price of entry for those nurses, the surcharge gives them less incentive to come to the country.

The Royal College of Nursing released some analysis last year, before this latest increase, showing that, if a nurse from a non-EU country came with two children to take a job at Band 5 (the average starting band for NHS nurses), “they would have to work from the start of the year until 22nd January, or for 116 hours, just to pay the £1,200 they will be billed under the current charge.” That was back when the surcharge was still £400. It is now 50% higher.

“Hard-working nurses from overseas who give their all for patients in the UK must not be penalised in this way any longer,” says Dame Donna Kinnair, Chief Executive and General Secretary of the Royal College of Nursing. “The Government must abolish this cruel and heartless charge for nursing staff”.

It’s not just nurses. There are many NHS role the country badly needs people to fill, not to mention other sectors. Shara Pledger, associate at the specialist immigration law firm Latitude Law, said the combination of the surcharge and regular contributions into the NHS via taxation is an unpalatable one.

“The announcement today of a further increase to £624 is unwelcome. Brexit, the end of free movement, and negative immigration rhetoric already serve to undermine the government message that Britain is ‘open for business’. Increases to the cost of relocation do not encourage migration. This is particularly problematic when a large cohort of workers the U.K. is trying to attract are future NHS staff; they face effective double taxation to pay themselves.”

Source: The U.K. Needs Immigrants To Work In Its Health Service. The Chancellor Just Gave Them A Reason Not To Come.

Race and Medicine: The Harm That Comes From Mistrust: Racial bias still affects many aspects of health care.

Good overview of the data and issues:

Racial discrimination has shaped so many American institutions that perhaps it should be no surprise that health care is among them. Put simply, people of color receive less care — and often worse care — than white Americans.

Reasons includes lower rates of health coverage; communication barriers; and racial stereotyping based on false beliefs.

Predictably, their health outcomes are worse than those of whites.

African-American patients tend to receive lower-quality health services, including for cancer, H.I.V., prenatal care and preventive care, vast research shows. They are also less likely to receive treatment for cardiovascular disease, and they are more likely to have unnecessary limb amputations.

As part of “The 1619 Project,” Evelynn Hammonds, a historian of science at Harvard, told Jeneen Interlandi of The New York Times: “There has never been any period in American history where the health of blacks was equal to that of whites. Disparity is built into the system.”

African-American men, in particular, have the worst health outcomes of any major demographic group. In part, research shows, this is a result of mistrust from a legacy of discrimination.

At age 45, the life expectancy of black men is more than three years less than that of non-Hispanic Caucasian men. According to a study in the Quarterly Journal of Economics, part of the historical black-white mortality difference can be attributed to a 40-year experiment by the U.S. Public Health Service that shook African-Americans’ confidence in the nation’s health system.

From 1932 to 1972, the Public Health Service tracked about 600 hundred low-income African-American men in Tuskegee, Ala., about 400 of whom had syphilis. The stated purpose was to better understand the natural course of the disease. To do so, the men were lied to about the study and provided sham treatments. Many needlessly passed the disease on to family members, suffered and died.

As one scholar put it, the Tuskegee study “revealed more about the pathology of racism than it did about the pathology of syphilis.” In fact, the natural course of syphilis was already largely understood.

The study was publicized in 1972 and immediately halted. To this day, it is frequently cited as a driver of documented distrust in the health system by African-Americans. That distrust has helped compromise many public health efforts — including those to slow the spread of H.I.V., contain tuberculosis outbreaks and broadenprovision of preventive care.

According to work by the economists Marcella Alsan and Marianne Wanamaker, black men are less likely than white men to seek health care and more likely to die at younger ages. Their analysis suggests that one-third of the black-white gap in male life expectancy in the immediate aftermath of the study could be attributed to the legacy of distrust connected to the Tuskegee study.

Their study relies on interpreting observational data, not a randomized trial, so there is room for skepticism about the specific findings and interpretation. Nevertheless, the findings are consistent with lots of other work that reveals African-Americans’ distrust of the health system, their receipt of less care, and their worse health outcomes.

The Tuskegee study is far from the only unjust treatment of nonwhite groups in health care. Thousands of nonwhite women have been sterilized without consent. For instance, between the 1930s and 1970s, one-third of Puerto Rican women of childbearing age were sterilized, many under coercion.

Likewise, in the 1960s and 1970s, thousands of Native American women were sterilized without consent, and a California eugenics law forced or coerced thousands of sterilizations of women (and men) of Mexican descent in the 20th century. (Thirty-two other states have had such laws, which were applied disproportionatelyto people of color.)

For decades, sickle cell disease, which mostly affects African-Americans, received less attention than other diseases, raisingquestions about the role of race in how medical research priorities are established.

A ‘Rare Case Where Racial Biases’ Protected African-Americans

Outside of research, routine medical practice continues to treat black and white patients differently. This has been documented in countless ways, including how practitioners view pain. Racial bias in health care and over-prescription of opioid painkillers accidentally spared some African-Americans from the level of mortality from opioid medications observed in white populations.

“While African-Americans may not have died at similar rates from opioid misuse, we can be sure needless suffering and, perhaps even death, occurred because provider racism prevented them from receiving appropriate care and pain medication,” said Linda Goler Blount, president and chief executive of the Black Women’s Health Imperative.

Of course, health outcomes are a result of much more than health care. The health of people of color is also unequal to that of whites because of differences in health behaviors, education and income, to name a few factors. But there is no doubt that the health system plays a role, too. Nor is there question that a history of discrimination and structural racism underlies racial differences in all these drivers of health.

Reinforcing the fact of racial bias in health care, a recent studyfound that care for black patients is better when they see black doctors. The study randomly assigned 1,300 African-Americans to black or nonblack primary care physicians. Those who saw black doctors received 34 percent more preventive services. One reason for this, supported by the study, is increased trust and communication.

The study findings are large. If all black men received the same increase in preventive services as those in the study (and received appropriate follow-up care), it would reduce the black-white cardiovascular mortality rate by 19 percent and shrink the total black-white male life expectancy gap by 8 percent, the researchers said.

But it is unlikely all black men could see black doctors even if they wished to. Although African-Americans make up 13 percent of the U.S. population, only 4 percent of current physicians — and less than 7 percent of recent medical school graduates — are black.

This study does not stand alone. A systematic review found that racially matched pairs of patients and doctors achieved better communication. Other studies found that many nonwhite patientsprefer practitioners who share their racial identity and that they receive better care from them. They view them as better than white physicians in communicating, providing respectful treatment and being available.

Racial bias in health care, as in other American institutions, is as old or older than the republic itself.

Title VI of the 1964 Civil Rights Act stipulates that neither race, color nor national origin may be used as a means of denying the “benefits of, or be subjected to discrimination under any program or activity receiving federal financial assistance.” As nearly every facet of the American health system receives federal financing and support, well-documented and present-day discrimination in health care suggests the law has not yet had its intended effect.

Source: Race and Medicine: The Harm That Comes From Mistrust

Public Services and Administration: What does the Census Say?

To what extent do public services and administration reflect and represent the population they serve? 

To start with, representation matters. The degree to which visible minority populations see themselves in public institutions both fosters and reflects integration, and facilitates how these institutions serve their citizens. This article uses census 2016 data to review how effectively education, healthcare, social services, police services and public administration at the national and provincial levels reflect diversity. Police services and public administration are also reviewed at the municipal level.

Overall, the analysis presents a mixed picture of visible minority representation, whether by area or government:

  • Significant under-representation at the elementary and secondary levels of education in contrast to comparable representation at the university level. Given that visible minorities are less likely to have degrees in education (only 7 percent of all 25-34 year olds are Canadian-born visible minority education graduates), this trend is unlikely to change quickly.
  • Healthcare and social services are broadly representative of the populations they serve. While median income data indicates most groups are reasonable well-represented at the professional level, with the exception of Filipinos, Blacks and Latin Americans, Canadian-born 25-34 year old visible minorities form 16.6 percent of those having healthcare degrees in this age cohort.
  • There is serious under-representation in the police of visible minorities among junior and senior officers, particularly of note in our largest cities. Of particular concern is the low level of “except commissioned” officers in Montreal, Edmonton, Calgary and Ottawa-Gatineau, indicating that under-representation is unlikely to be addressed soon. This under-representation likely contributes to some of the tensions between communities (i.e., Black Canadians) and police. The lack of effective employment equity reporting by most police forces is symptomatic of a lack of attention to this issue.
  • The federal public service is reasonably representative of the number of visible minorities who are also citizens, while the provinces and municipalities are less so in most provinces. Median income data shows considerable variation by level of government and visible minority group, particularly for Blacks, Filipinos and Arabs.

Charts and analysis 

Chart 1

Chart 1 provides the gender breakdown in education, healthcare and social services using the North American Industry Classification System (NAICS). The percentage of women declines as the level of education increases; the percentage of women is similar in ambulatory services (doctors and dentist offices) and hospitals, and somewhat greater in nursing homes. For social services (individual and family services), the percentage of women is similar to healthcare but childcare is 92 percent women.

Chart 2

Chart 2 illustrates the median employment incomes for all generations of visible minorities  working in these sectors. Given standard public sector pay scales, the variation reflects a combination of whether visible minorities are professionals or in support positions along with seniority (ambulatory excepted). The relatively low median inco mes of visible minorities compared to not visible minority (NVM) in all levels of education is striking, as is the higher median incomes in hospitals and nursing homes in healthcare. Median income of visible minorities in social services is largely comparable to NVM, likely reflecting relatively low salary bands and classification levels.

Chart 3

Chart 3 takes a closer look at visible minority representation in the education sector, contrasted  with the overall diversity of the population. 792,000 persons work in elementary and high schools, by far the largest area (11.7 percent visible minority), 92,000 in community colleges and CEGEPS (13.7 percent visible minority), and 224,000 in universities (23.7 percent visible minority). Women comprise the majority at all three levels: elementary and secondary schools (73.6%), community colleges and CEGEPs (57.9%) and universities (54.1%).

 In essence, students at the elementary and college levels are less likely to be taught by visible minority educators. In all provinces, the higher the level of education, the greater the number of visible minorities, with Canada-wide university representation (professors and support staff) reflecting the overall population levels.

Median income data provides insights on the extent to which visible minority groups are in professional or support positions. For elementary and secondary schools, all groups, save Chinese (8% lower) and Japanese Canadians (8 percent higher), have a disproportionate share of support positions and/or lower seniority (10 percent difference) compared to not visible minority (NVM). For community colleges and CEGEPs, all groups have significantly lower median incomes than NVM with Japanese Canadians having the least difference (6 percent). For universities, despite the overall greater diversity, median income data suggest that visible minorities are concentrated in more junior positions and support staff.

Chart 4

Chart 4 provides the provincial breakdown, once again contrasting provincial populations with representation in the education sector where the overall pattern of greater university level representation and relative under-representation at the elementary and secondary levels can be  seen. In the largest provinces, university representation is broadly reflective of the population; in smaller provinces, university representation is significantly greater than the population.

Chart 5

Chart 5 compares the overall visible minority population with those working in healthcare and  social services. 

Approximately 1.5 million persons work in healthcare: 564,000 in ambulatory services, 632,000 in hospitals and 328,000 in nursing homes. About 344,000 work in social services, of which 149,000 in individual and family services and 194,000 in childcare.

Starting with healthcare, group representation varies by sector. The major visible minority groups are represented in all sectors shown with some relative over-representation of Chinese in ambulatory services, Blacks in hospitals, nursing homes, and social services, Filipinos in all sectors and Arabs dramatically so in childcare.

Median income data indicate that South Asians, Chinese, Arabs and Southeast Asians are more likely to be in professional positions in doctor offices; Chinese, Southeast Asians, Korean and Japanese in dental offices. Hospital median income data highlight that South Asians, Chinese, West Asians, Korean and Japanese are more likely to be in professional positions. Groups that tend to be more in support positions are Filipino, Black and Latin American.

Chinese, Arab, West Asian and Korean are over-represented by men compared to not visible minority (10 percent difference), with the relative gender gap particularly high for Arabs (23 percent).

Chart 6

Chart 6 provides the healthcare visible minority representation by province, reflecting the overall pattern of representation comparable to the visible minority population, with noticeable over-representation of visible minorities in nursing homes.

Visible minorities are over-represented in Manitoba and Saskatchewan (hospitals and nursing homes only), and the under-representation in Quebec ambulatory services likely reflects the low visible minority population outside of Montreal and environs. 

Chart 7

Chart 7 contrasts the visible minority workers in social services and childcare, again reflecting the overall  national pattern, with the striking over-representation of visible minorities in childcare in most provinces.

Chart 8

Chart 8 provides the national breakdown of visible minority police officers, separated out by commissioned (senior) and “except commissioned” (junior) officers, again contrasted with the overall visible minority population. There are 2,015 commissioned officers and 75,670 non-commissioned officers. Given mixed to limited reporting by police forces, this provides the best measure of police force diversity.

As one would expect, not commissioned officer diversity is greater than the senior ranks, providing a feeder group to increase commissioned officer diversity over time.

Chart 9

Chart 9 looks at the diversity of police forces in six of Canada’s largest cities. It is a mixed picture: while the overall pattern of under-representation remains, in some cities the percentage of visible minority commissioned officers is greater than not commissioned, suggesting a conscious decision to ensure greater representation at senior levels (e.g., Toronto, Edmonton).

Equally striking is the relative lack of visible minority police in Montreal (both commissioned and except commissioned), Calgary (no visible minority commissioned officers) and Edmonton (except commissioned). 

The integrated numbers for Ottawa Gatineau disguise significant differences: whereas in Ottawa visible minority commissioned officers form 8.7 percent, except commissioned 8.5 percent, in Gatineau there are no visible minority commissioned officers and only 2.9 percent of except commissioned officers are visible minorities

Chart 10

Census data provide a useful counterpoint to the annual Treasury Board Secretariat (TBS) employment equity reports. TBS reports have a richer dataset than the Census (regional, occupational group, salary, age and other breakdowns) but they only cover Schedule 1 bodies and do not include Schedule 2 bodies (e.g., CRA, CFIA, CSIS, NRCE, Parks Canada) or Schedule 3 (Crown corporations) and do not provide a breakdown by visible minority groups. Census data also provide consistent data at the provincial and municipal levels. The population benchmark used is that of visible minorities who are also Canadian citizens, given the preference in hiring citizens.

Chart 10 not only provides the overall visible minority representation, but breaks this down by the different visible minority groups. About 317,000 persons work in federal public administration (all except defence), 269,000 in provincial public administration and 340,000 in municipal. Significantly more women than men work in federal and provincial public administration (55.6 and 58.9 percent respectively) whereas municipal public administration is majority male (60.6 percent), reflecting the nature of municipal services (e.g., garbage collection, road maintenance).

At the federal level, only Chinese, Arabs and Japanese public servants reflect or are greater than the overall visible minority citizen population. All other groups are under-represented by 10 percent or more. 

Chart 11

Chart 11 contrasts provincial and municipal public administrations with the overall number of visible minority citizens. Provincial visible minority public servants largely mirror the overall number of visible minorities with the notable under-representation in British Columbia and slight overrepresentation in Alberta, Manitoba, and Saskatchewan. Municipal pu blic administration visible minority public servants are under represented in all provinces save Saskatchewan and Atlantic Canada, and in some cases, significantly as is the case in Ontario, Quebec and British Columbia.

All groups, save Black, are underrepresented at the provincial level and all groups save Japanese are under-represented at the municipal level.

Chart 12

Chart 12 compares the median income of visible minority groups compared to not visible minority for each level of government, providing an indication of whether groups are in more senior or junior positions.

Only Chinese and Japanese public servants have higher median incomes for all three levels of government. South Asian provincial public servants, Black and West Asian municipal public servants and Korean provincial public servants also have higher median incomes. The greatest gaps in median incomes are for Black (save municipal), Filipino, Latin American and Arab (save federal). 

Addiction Kills More Blacks, But Treatment Is Prescribed Mostly To Whites

Yet another study on the disparities in healthcare:

White drug users addicted to heroin, fentanyl and other opioids have had near exclusive access to buprenorphine, a drug that curbs the craving for opioids and reduces the chance of a fatal overdose. That’s according to a study out Wednesday from the University of Michigan. It appears in JAMA Psychiatry.

Researchers reviewed two national surveys of physician-reported prescriptions. Between 2012 and 2015, as overdose deaths surged in many states, so did the number of visits during which a doctor or nurse practitioner prescribed buprenorphine, often referred to by its brand name, Suboxone. The researchers assessed 13.4 million medical encounters involving the drug but found no increase in prescriptions written for African Americans and other minorities.

“White populations are almost 35 times as likely to have a buprenorphine-related visit than black Americans,” says Dr. Pooja Lagisetty, an assistant professor of medicine at the University of Michigan Medical School and the study’s corresponding author.

The dominant use of buprenorphine to treat whites occurred at the same time opioid overdose deaths were rising faster for blacks than for whites.

“This epidemic over the last few years has been framed by many as largely a white epidemic, but we know now that’s not true,” Lagisetty says.

What is true, Lagisetty added, is that most of the white patients either paid cash (40%) or relied on private insurance (35%) to fund their buprenorphine treatment. The fact that just 25% of the visits were paid for through Medicaid and Medicare “does highlight that many of these visits could be very costly for persons of low income,” Lagisetty says.

Doctors and nurse practitioners can demand cash payments because there’s a shortage of clinicians who can prescribe buprenorphine, according to Dr. Andrew Kolodny, co-director of Opioid Policy Research at Brandeis University. Only about 5% of physicians have taken the special training required to prescribe buprenorphine.

“The few that are doing it are really able to name their price, and that’s what we’re seeing here and that’s the reason why individuals with more resources — who are more likely to be white — are more likely to access treatment with buprenorphine,” says Kolodny, who was not involved in the study.

Kolodny wants the federal government to eliminate the required special training for buprenorphine and a related cap on the number of patients a doctor can manage on the drug.

Some physicians who have studied racial disparities in addiction treatment say the root causes go back to 2000, when buprenorphine was approved. At that time, proponents argued that buprenorphine was needed to help treat suburban youth, says Dr. Helena Hansen at New York University. Those young patients didn’t see themselves as addicted to heroin in the same way as hard-core urban heroin users who went to methadone clinics for treatment, she says.

“Buprenorphine was introduced as private office treatment, for a private market, with the means to pay,” says Hansen, an associate professor of psychiatry and anthropology. “So the unequal dissemination of buprenorphine for opioid dependence is not accidental.”

Hansen added that the fix must include universal access to treatment in a primary care setting, an end to the criminalization of opioid dependence (which puts more blacks in prison for drug use than whites), and more federal funding to expand access to buprenorphine for all patients.

Several leaders in the fight to reduce opioid overdose deaths say the study results are disturbing.

“It really demands for us to be looking at equitable treatment for addiction for African Americans as we do for white Americans,” says Michael Botticelli, director of the Grayken Center for Addiction at Boston Medical Center and the former director of the Office of National Drug Control Policy.

Botticelli identified some key issues that may be contributing to the racial treatment gap that deserve further investigation. For example, he wants to know whether Medicaid reimbursement rates are simply too low to entice more doctors to work with low-income patients, or there are too few inner-city doctors prescribing buprenorphine, or African Americans themselves are somehow reluctant to seek this form of treatment.

Dr. Nora Volkow, director of the National Institute on Drug Abuse at the National Institutes of Health, called the findings surprising and disturbing. Surprising because the disparity is so large, and disturbing because her agency has prioritized educating doctors about the value of prescribing buprenorphine.

Volkow also expressed disappointment that federal parity laws, which are supposed to guarantee equal access to all types of medications, don’t seem to be working for buprenorphine. “We need to ensure that we have capacity to provide these treatments,” Volkow says. “Because if you say you have to pay for them, but there are no services that can provide the treatments, then the issue of paying for them is secondary.”

Volkow has noted that fewer than half of Americans with an opioid use disorder have access to buprenorphine or the two other medications used to treat opioid addiction: methadone and naltrexone. Volkow said she is glad that the use of buprenorphine is on the rise, but the U.S. needs to understand why this lifesaving treatment isn’t benefiting all patients who need it.

Source: Addiction Kills More Blacks, But Treatment Is Prescribed Mostly To Whites