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Affirmative action
Affirmative action See Editorial page 765
Sir—Your Jan 2 editorial1 on the rollback of affirmative action in the USA in medicine, in particular, correctly notes that African Americans constitute 13·8% of the American population, and yet, are only 2·9% of the US physican workforce. This discrepancy is largely the result of centuries of institutionally enforced racism in one form or another. The civil rights revolution of the 1960s heralded the beginning of the second US reconstruction period inclusive of affirmative action. The social progress made by people of colour and white women has been nothing short of remarkable. Unfortunately, during the 1990s we witnessed the end of this second reconstruction period. Consequently, the potential future negative implications of recent social rollback efforts combined with the continued social isolation of a disproportionate number of African Americans in education and housing, raise troubling questions of intent and good faith, when trying to remedy this community’s health problems. Recent social regression efforts have increasing importance when one considers that 30% of African-American citizens are cared for by AfricanAmerican physicians.2 Of course, these concerns would not be as contentious if the medical care provided to some African-Americans were not so disturbing in its implications. Perhaps these reports3 can give us insight into the potential implications of the chronic African-American provider shortage, and the suggestion of racial discrimination in the provision of health care. A disturbing study,3 paid for by the New York state health department, examined the records of 1261 patients who were thought to be candidates for bypass surgery but did not undergo the procedure between 1994 and 1996. Race, unsurprisingly, was a substantial factor in determining who got the most aggressive cardiac care. The study investigators reported that even though African Americans with disease so severe that bypass surgery was appropriate and necessary within 3 months, they were still 40% less likely to receive such surgery than whites. When researchers questioned the doctors who refused to recommend bypass surgery, 90% answered that they, rather than the patient, had made the decision not to treat. Unfortunately, mortality data were not reported, but Petersen and his group showed that African Americans who did not undergo
THE LANCET • Vol 353 • March 6, 1999
surgery had higher mortality rates than white Americans at 5 years.3 Moreover, recent data on death rate ratios for ischaemic heart disease in the USA between 1980 and 1995 revealed a worsening death rate disparity for blacks compared with whites.4 Reasons usually given for the worsening disparity in excess mortality—namely, smoking, sedentary lifestyle, alcohol consumption, and obesity—have been questioned by Lantz and colleagues.5 These workers noted that “only 12–13% of excess mortality in the lower socioeconomic classes were related to the usual risk factors and . . . that we must look at a broader range of explanatory risk factors, including structural elements of inequality in our society.” Would the lack of access to bypass surgery qualify as one of the structural elements? The humanitarian implications on the issue of less aggressive cardiac care given to African Americans is intolerable and raise troubling questions. What can be done to remedy racial discriminatory practices in the allocation of necessary diagnostic tests and treatments? George Dawson The Afrikan-American National Freedom and Science Institute, Harlem, New York 10027, USA 1
Editorial. Affirmative action. Lancet 1999; 353: 1. 2 Byrd W, Clayton L, Kinchen K, et al. African American physicians’ views on health reform: results of a survey. J Natl Med Assoc 1994; 86: 191–99. 3 Hannan E, Van Ryn M, Burke J, et al. Access to coronary artery bypass surgery by race/ethnicity and gender among patients who are appropriate for surgery. Med Care 1999; 37: 68–77. 4 Huston S, Lengerich E, Conlisk E, et al. Trends in ischemic heart disease death rates for blacks and whites—United States, 1981–1995. MMWR Morb Mortal Wkly Rep 1998; 47: 945–49. 5 Lantz P, House J, Lepkowski J, et al. Socioeconomic factors, health behaviors, and mortality. JAMA 1998; 279: 1703–08.
Sir—In your editorial1 you make the case for discrimination in favour of ethnic minorities at the point of medical school entrance. You have supplied some facts indicating that such affirmative action, or positive discrimination as it has more recently been referred to, increases the proportion of ethnic minorities that apply to medical school. You then go on to say that the Association of American Medical Colleges (AAMC) has told you that doctors from ethnic minority backgrounds are more likely to pursue careers in underserved minority communities. I reject your arguments as a matter of principle and also as a matter of fact. You argue that the end justifies the means. I would say these ends can be
achieved by other less objectionable means. Affirmative action is discrimination in itself, and it establishes respectability for ethnic and other forms of discrimination. If you reject discrimination as a point of principle, then it is illogical to embrace it when it suits your needs. Although I appreciate your editorials have to be short, when dealing with the possible benefits of affirmative action, all you do is relay the AAMC’s opinion. These benefits are far from self-evident. What real evidence do they have that a higher proportion of ethnic minority medical students practise in underserved minority communities? I am not at all sure that it is the role of the medical school selection board to balance discrimination in wider society. If your wish is truly to supply high quality medical graduates to work in underserved minority communities, could this goal not be achieved by offering scholarships to students from certain schools or certain localities, and then, if necessary, requiring the students, on graduation, to work in those localities or similarly deprived ones elsewhere for a period after graduation? We must resist any misguided attempts to introduce such discrimination into medical school selection in the UK. W Sunman Ivy Cottage, Main Street, Epperstone, Nottingham NG14 6AU, UK 1
Editorial. Affirmative action. Lancet 1999; 353: 1.
Developing country twinning programmes in paediatric oncology Sir—The success of the La Mascota twinning programme (Dec 12, p 1923)1 in paediatric haemato-oncology between two developed (Switzerland and Italy) and one less developed country (Nicaragua) is a landmark achievement, which presents the twinning approach as a realistic challenge. In sub-Saharan Africa the need for fostering this type of linkage is a high priority because the management and follow-up of children with cancer in many malaria-endemic regions is unsatisfactory. Burkitt’s lymphoma is the most common cancer among children in sub-Saharan Africa and its pattern and incidence are directly associated with malaria transmission. In this region up to 50% of all tumours in children are lymphomas, with less than 10% due to leukaemia. In non-malarious developed countries this pattern is reversed. Despite this high
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Sir—Your Jan 2 editorial1 on the rollback of affirmative action in the USA in medicine, in particular, correctly notes that African Americans constitute 13·8% of the American population, and yet, are only 2·9% of the US physican workforce. This discrepancy is largely the result of centuries of institutionally enforced racism in one form or another. The civil rights revolution of the 1960s heralded the beginning of the second US reconstruction period inclusive of affirmative action. The social progress made by people of colour and white women has been nothing short of remarkable. Unfortunately, during the 1990s we witnessed the end of this second reconstruction period. Consequently, the potential future negative implications of recent social rollback efforts combined with the continued social isolation of a disproportionate number of African Americans in education and housing, raise troubling questions of intent and good faith, when trying to remedy this community’s health problems. Recent social regression efforts have increasing importance when one considers that 30% of African-American citizens are cared for by AfricanAmerican physicians.2 Of course, these concerns would not be as contentious if the medical care provided to some African-Americans were not so disturbing in its implications. Perhaps these reports3 can give us insight into the potential implications of the chronic African-American provider shortage, and the suggestion of racial discrimination in the provision of health care. A disturbing study,3 paid for by the New York state health department, examined the records of 1261 patients who were thought to be candidates for bypass surgery but did not undergo the procedure between 1994 and 1996. Race, unsurprisingly, was a substantial factor in determining who got the most aggressive cardiac care. The study investigators reported that even though African Americans with disease so severe that bypass surgery was appropriate and necessary within 3 months, they were still 40% less likely to receive such surgery than whites. When researchers questioned the doctors who refused to recommend bypass surgery, 90% answered that they, rather than the patient, had made the decision not to treat. Unfortunately, mortality data were not reported, but Petersen and his group showed that African Americans who did not undergo
THE LANCET • Vol 353 • March 6, 1999
surgery had higher mortality rates than white Americans at 5 years.3 Moreover, recent data on death rate ratios for ischaemic heart disease in the USA between 1980 and 1995 revealed a worsening death rate disparity for blacks compared with whites.4 Reasons usually given for the worsening disparity in excess mortality—namely, smoking, sedentary lifestyle, alcohol consumption, and obesity—have been questioned by Lantz and colleagues.5 These workers noted that “only 12–13% of excess mortality in the lower socioeconomic classes were related to the usual risk factors and . . . that we must look at a broader range of explanatory risk factors, including structural elements of inequality in our society.” Would the lack of access to bypass surgery qualify as one of the structural elements? The humanitarian implications on the issue of less aggressive cardiac care given to African Americans is intolerable and raise troubling questions. What can be done to remedy racial discriminatory practices in the allocation of necessary diagnostic tests and treatments? George Dawson The Afrikan-American National Freedom and Science Institute, Harlem, New York 10027, USA 1
Editorial. Affirmative action. Lancet 1999; 353: 1. 2 Byrd W, Clayton L, Kinchen K, et al. African American physicians’ views on health reform: results of a survey. J Natl Med Assoc 1994; 86: 191–99. 3 Hannan E, Van Ryn M, Burke J, et al. Access to coronary artery bypass surgery by race/ethnicity and gender among patients who are appropriate for surgery. Med Care 1999; 37: 68–77. 4 Huston S, Lengerich E, Conlisk E, et al. Trends in ischemic heart disease death rates for blacks and whites—United States, 1981–1995. MMWR Morb Mortal Wkly Rep 1998; 47: 945–49. 5 Lantz P, House J, Lepkowski J, et al. Socioeconomic factors, health behaviors, and mortality. JAMA 1998; 279: 1703–08.
Sir—In your editorial1 you make the case for discrimination in favour of ethnic minorities at the point of medical school entrance. You have supplied some facts indicating that such affirmative action, or positive discrimination as it has more recently been referred to, increases the proportion of ethnic minorities that apply to medical school. You then go on to say that the Association of American Medical Colleges (AAMC) has told you that doctors from ethnic minority backgrounds are more likely to pursue careers in underserved minority communities. I reject your arguments as a matter of principle and also as a matter of fact. You argue that the end justifies the means. I would say these ends can be
achieved by other less objectionable means. Affirmative action is discrimination in itself, and it establishes respectability for ethnic and other forms of discrimination. If you reject discrimination as a point of principle, then it is illogical to embrace it when it suits your needs. Although I appreciate your editorials have to be short, when dealing with the possible benefits of affirmative action, all you do is relay the AAMC’s opinion. These benefits are far from self-evident. What real evidence do they have that a higher proportion of ethnic minority medical students practise in underserved minority communities? I am not at all sure that it is the role of the medical school selection board to balance discrimination in wider society. If your wish is truly to supply high quality medical graduates to work in underserved minority communities, could this goal not be achieved by offering scholarships to students from certain schools or certain localities, and then, if necessary, requiring the students, on graduation, to work in those localities or similarly deprived ones elsewhere for a period after graduation? We must resist any misguided attempts to introduce such discrimination into medical school selection in the UK. W Sunman Ivy Cottage, Main Street, Epperstone, Nottingham NG14 6AU, UK 1
Editorial. Affirmative action. Lancet 1999; 353: 1.
Developing country twinning programmes in paediatric oncology Sir—The success of the La Mascota twinning programme (Dec 12, p 1923)1 in paediatric haemato-oncology between two developed (Switzerland and Italy) and one less developed country (Nicaragua) is a landmark achievement, which presents the twinning approach as a realistic challenge. In sub-Saharan Africa the need for fostering this type of linkage is a high priority because the management and follow-up of children with cancer in many malaria-endemic regions is unsatisfactory. Burkitt’s lymphoma is the most common cancer among children in sub-Saharan Africa and its pattern and incidence are directly associated with malaria transmission. In this region up to 50% of all tumours in children are lymphomas, with less than 10% due to leukaemia. In non-malarious developed countries this pattern is reversed. Despite this high
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