A strategy to tame the "savage inequalities".
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Biomedical subjects
Publications and source records attributed to H W Nickens.
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Minority health is often considered as a unitary phenomenon; it is often assumed that the health status of minority groups in the United States is similar across groups and much worse than that for whites. Yet the reality is extraordinary diversity. Racial/ethnic groups differ greatly both among and within themselves with regard to health status and with regard to a large number of other indices. Mortality rates around the world generally show an inverse relationship with social class. While this generally holds true in the United States as well, once again we see a strong interaction with race/ethnicity. However, the mediating factors between race/ethnicity and social class, and health status are not well understood. Especially in the face of health care reform, a broad-based research agenda needs to be undertaken so that any restructuring of the health care delivery system is informed by empirical information.
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The authors discuss the decline in the numbers of black men enrolling in medical school over the last two decades and assess possible reasons for it, including the smaller numbers of men from nearly all races and ethnic groups now applying to medical school, the declining popularity of the undergraduate biology degree among men in general, the falling number of black students who go on to college, and, underlying all these, the pervasive effects of poverty on educational achievement, the dwindling employment opportunities for black men of limited education (brought on by dramatic changes in the American economy), and the rising indices of stress and alienation among black men. The authors review the larger social implications of the growing educational gap between black men and other segments of society, pose questions about some of the trends that have been mentioned, indicate lines for further research, and propose potential solutions to the problem of the deepening underrepresentation of black men in medical schools.
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There is increasing national recognition that while our nation's health care system is the most expensive in the world, the health care status of Americans overall ranks poorly compared with other Western, industrialized nations. In the United States we tend to look at minority-majority variations of health status, as well as the variations of many other indicators by race or ethnicity, because race and ethnicity are particularly important components of our society. In general, health status indicators of minority Americans are worse than those of whites. In some locales, death rates of minority Americans are comparable to those of Third World nations. At the same time, minority Americans make up a rapidly increasing proportion of the nation's population and work force. Our baseline national data on some minority groups, however, currently are inadequate to detect shifts in health status. Finally, the rapidly expanding problem of the acquired immunodeficiency syndrome among some minority populations provides both an imperative and an opportunity to learn how model prevention programs should be designed and executed.
Since 1970 the Association of American Medical Colleges (AAMC) has had two key policies about minorities in medicine: (1) special attention should be paid to minority groups underrepresented in medicine, and (2) minority groups should be represented in medicine in the same proportions as in the population as a whole. Despite strong gains in the 1970s in increasing the number of black trainees and graduates, the proportion of minorities in medicine now is declining in relation to the total population. The paper discusses this situation, changes in U.S. minority populations, factors that affected the attempt to achieve parity in medicine, the current status of minorities in medical training (including educational debt) and on medical faculties, and remedies for institutions' lack of success in achieving parity. Three successful programs are described, as are the broader social issues that underlie academic medicine's attempt to increase the proportion of minorities in medicine.
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Heart disease and stroke have been the first and third leading causes of death, respectively, in the United States for many years, and the importance of primary and secondary prevention in reducing morbidity and mortality from these two disease entities has been well established. Additional confirmatory information continues to accumulate, but it is accepted that hypertension, smoking, and serum lipids are important risk factors in coronary heart disease and stroke. Although this discussion deals primarily with cardiovascular disease, many of the issues related to prevention and medical education are generic and are equally relevant to the prevention of other diseases, including HIV infection. Moreover, the way in which medical education approaches preventive cardiology is likely to be similar to the way in which prevention issues are approached in general.
In the last half of the 19th century, medicine was becoming organized. In Washington, DC, in 1870, the attempt by black physicians to join the local medical society met with fierce and successful resistance. Ultimately, a separate, racially integrated medical society was formed. One hundred years ago, it became the still-vital Medico-Chirurgical Society of the District of Columbia, the local branch of the National Medical Society.
Psychiatry is in ferment. In the present sluggish economy nonphysician psychotherapists, often charging lower fees, are competing with psychiatrists for patients. At the same time theories and therapies that can be characterized as psychodynamic appear to be on the defensive, increasingly challenged by those with behavioral or psychopharmacologic foundations. A growing emphasis on statistical rigor in research increases this phenomenon. One general response to all of this by the psychiatric profession has been a reassertion of psychiatry's connections and identification with medicine and with science. The author contends that although this response is understandable and may provide some support for the prestige of psychiatry, the issue at hand is fundamentally an epistemologic one. It is a deeply rooted and structural dilemma.
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