Why was Thomas Eric Duncan, a Liberian national infected with Ebola, sent home when he first sought treatment at a Dallas hospital? The question is an unsettling one, not only because the failure to follow proper protocols may have cost him his life and placed others at risk of contracting the disease. It's also unsettling because Duncan's death and the current Ebola outbreak point to broad and systemic racial disparities in treatment and access to care in the U.S. and abroad.
Many have already written about the glaring global health inequities evident by the ability of privileged Americans to be quickly airlifted back to the U.S. for experimental treatment while the death count in West Africa ticks up at an alarming pace. The three white Americans treated at Emory University Hospital and Nebraska Medical Center survived. Why didn't Duncan?
After retracting its initial story placing blame on a "flaw" in its electronic health record system, Texas Health Presbyterian Hospital has yet to provide an explanation as to why Duncan's case was handled in the manner that it was. Before Duncan's death, Dallas county commissioner John Wiley Price suggested that Duncan's lack of health insurance may have played a part in the hospital's decision to release him after initially complaining of a fever and abdominal pain.
"I said at the outset, Presbyterian is a boutique hospital next to a little Ellis Island," Price said, referring to the immigrant community where the hospital is located. "If you don't have insurance, you're not going to get treated. That's the elephant in the room."
Duncan had many of the characteristics which data consistently show are likely to result in disparate treatment: lack of insurance, black, foreign nationality and (likely) an accent. While we wait for further information on what exactly happened at the Dallas hospital where Duncan was treated, the nation is long overdue for a national conversation about health care disparities. Such a conversation seemed prime to happen in the context of the debate of the Affordable Care Act, but the law became so racialized that it appeared that many including the Obama administration feared making any explicit references to racial inequities in health care until after the law was passed.
Health disparities are costly not only in lives but in the financial burden they impose on individuals as well as the health care system. Differential treatment of racial and ethnic minorities often results in delays in care, less aggressive treatment compared to whites with similar presentation of disease or symptoms, and worse health outcomes. Even with health insurance and similar socioeconomic status, racial and ethnic minorities receive lower quality of care than whites.
The history of racism in American medicine has meant countless blacks have been turned away or given the minimal amount of care necessary when circumstances suggested a higher level of response was appropriate. We know about Duncan's plight partly because of increased public fear in the U.S., and the delayed, but now global concern about how a virus that has successfully been contained in the past, was allowed to kill more than 3300 people within a matter of months.
Health care providers are humans and not infallible, however systematic changes in clinical settings and policies on a national level can help reduce the likelihood that biases due to insurance status, race, national origin or other factors don't cloud clinical judgments and limit treatment options. Unconscious biases can affect how physicians and other health care providers treat people of color, immigrants and patients with language barriers. Health care workers must be made aware of these tendencies and provided with training to reduce unconscious biases in clinical decision-making. Hospital policies must also be put in place to ensure every patient receives quality and timely care.
The Affordable Care Act includes a number of important provisions that are intended to increase the cultural competency of health care workers and provide more data on progress in eliminating health care disparities. It's still early to know whether these requirements are working to make a difference in how people of color are treated when they seek care. But Duncan's case contrasted with the Americans who were flown back to the U.S. for treatment raises important questions about the role of race, privilege, power and money in shaping one's health care experiences and ultimately one's survival.
These are not new questions for public health or medical ethicists. The Ebola outbreak, however, forces an important discussion about how the commodification of health care often means in the face of public health crises, people of color, the poor and those in developing countries are almost certainly fated for unequal treatment and death.