- Email: [email protected]
Improving access and quality for ethnic minority women—panel discussion
3. NHS. Our Healthier Nation. National Service Framework for Coronary Heart Disease: Modern Standards and Service Models. Department of Health; March 2000. 4. Department of Health. Savings Lives: Our Healthier Nation. London: Stationery Office; July 1999. 5. Minority Ethnic Issues in Social Exclusion and Neighbourhood Renewal: A Guide to the Work of the Social Exclusion Unit and the Policy Action Teams so far. Modernising Government, Cabinet Office; June 2000. 6. Bahl V. Asian Mother and Baby Campaign. Report by the Director. London: Department of Health; 1987. 7. Department of Health. The New NHS Modern Dependable. London: The Stationery Office; December 1997. 8. NHS. The NHS Plan: A Plan for Investment, A Plan for reform. HMSO. July 2000. 9. Department of Health. Independent Inquiry into Inequalities in Health Report. London: The Stationery Office; 1998. 10. Rawaf S, Orton P. Current Issues in Healthcare - Health Improvement Programmes - Minority Ethnic Health. London: The Royal Society of Medicine Press Ltd.; 2000. 11. Bahl V, Rawaf S. Assessing the Health Needs of People from Minority Ethnic Groups. London: Faculty of Public Health Medicine; 1998. 12. NHS Executive. The NHS Performance Assessment Framework. Crown Copyright. Department of Health; March 1999.
Improving Access and Quality for Ethnic Minority Women— Panel Discussion Intersections of Institutional Racism, Socioeconomic Status, Language, and Culture on Women’s Health Ruth E. Zambrana, PhD Department of Women’s Studies University of Maryland College Park, Maryland
INTRODUCTION As I reviewed the two prepared papers, I was intellectually struck by both the tone and depth of understanding reflected and articulated by Drs. Gaston and Bahl’s comments regarding key factors that differently influence the health status of women of color, both in the United States and the United Kingdom. My comments focus on three areas: institutionalized forms of racism, culture and language, and strategies for change. These areas, in my view, are the most intellectually and personally challenging, as we seek to expand our understanding of the health of women of color.
INSTITUTIONAL FORMS OF RACISM Institutional forms of racism as evidenced by lower quality of care for poor women and women of color have been adequately documented in the last 354
WOMEN’S HEALTH ISSUES VOL. 11, NO. 4 JULY/AUGUST 2001
© 2001 by the Jacobs Institute of Women’s Health Published by Elsevier Science Inc. 1049-3867/01/$20.00 PII S1049-3867(01)00109-8
10 years.1–3 Investigators have attempted to measure both obvious and subtler institutional forms of racism that extend on a continuum from the change in attitude of a receptionist when a women of color walks up to a desk, to a physician making a clinical decision not to order a mammogram for a Hispanic woman,4 or other clinically important procedures for an African American woman.5 Unfortunately, although we know that varying forms of racism exist in our health care system and are detrimental to poor people and people of color, in the United States, we tend to shy away from the language that defines the illness of racism.6 Utilizing current mortality and morbidity indicators as our yardstick,7 evidence suggests that institutionalized forms of racism are linked to both access and quality of care for all people of color, but are particularly detrimental to African American and some Latino subgroups. The central question is— how do we decrease or eliminate racial and ethnic disparities among women of color if we hesitate to speak it? Define it? Measure it?
CULTURE AND LANGUAGE Another current and paramount issue that emerges concerns the unqualified attribution of the variables of culture and language as major predictors of health outcome for the Hispanic/Latino population, without acknowledging or taking into account the dynamic and powerful intersection of poverty or low socioeconomic status (SES) with the culture, language, literacy, education level, and political climate of a host country. Culture and language issues have become more salient in the last 10 years with the influx of many immigrant groups. However, the importance of sociocultural factors in relation to health outcome have long been advocated as important, especially with regard to African Americans, and historically under-represented Mexican-origin and Puerto Rican subgroups, both in the United States and on the island of Puerto Rico.8 Although both presenters acknowledge the importance of socioeconomic status as a major barrier to health care access and quality, its significance and the import of the hierarchical mechanisms through which poverty influences all aspects of quality of life and health outcome were not amply discussed. In examining the factors that influence the lives of poor women of color, we need to advance our thinking and understanding that basic rights to access and quality of care are not available to most poor and working-class women. For example, many poor women do not have employment-linked health benefits and/or the money to pay for insurance.9 If they are married or in a partnership, their partners may often not have employment-linked payments or may be unable to afford the cost of family health insurance. Thus, access issues require structural remediation and increased responsiveness to women by providers, if racial and ethnic disparities are to be reduced over the next decade.10 Women with less education have been found to be more intimidated by physician authority, and less likely to ask questions. Studies have shown that physicians are less likely to recommend screening tests and other referrals to women of color in general,4,5 and to poor women in particular. In my work and other empirical work reviewed, there appears to be a merging consensus that, although culture and language are important, we need to elevate the primacy of SES as a marker of education and literacy level that more strongly influences health of low-income Hispanic/Latino women than do culture and even language.4 Low socioeconomic status is closely associated with less access to and knowledge about favorable health care practices, more trusting or less trusting attitudes toward health care providers, less skills to successfully
© 2001 by the Jacobs Institute of Women’s Health Published by Elsevier Science Inc. 1049-3867/01/$20.00
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navigate the health care system, and less ability to afford the costs of the health care system. Not surprisingly, several studies have found that when access is available and education level is high, language is not a major predictor of outcome.11 In general, higher education level, associated with English-language proficiency, higher literacy levels, and employment-linked benefits is a stronger predictor of access, use of health care services and outcome than culture or language. For Latinas, these characteristics vary substantially by subgroup and must be acknowledged and measured.12 My observations and experience suggest that it is easier for us as a nation to talk about culture and language than to talk about socioeconomic status, literacy, poverty, and inequity. These concepts challenge our basic value system of equality for all. However, to address disparities and inequities, there is a need to identify and target policies for all racial and ethnic groups who remain at economic and social disadvantage, but especially for women of Hispanic/Latino subgroup origin. The Latinas, who constitute the poorest group of minority women, are most at risk of being disproportionately burdened by language and cultural factors. Poverty, as it intersects with these factors, can exacerbate health disparities. Notably, language and culture are central to the Latino experience, whether they are U.S. born or foreign born. Overall, 67% of all Latinos are U.S. born or naturalized citizens and 87% of Latino children are U.S. born or naturalized citizens. Close to three-quarters (74%) report speaking English well. Although the more recent the immigration, the less likely a person is to speak English, not all immigrants have experienced the same type and level of barriers as Latino immigrants.13 In a recent article, The Two Meanings of Social Capital,14 the author provides an additional context in which to understand differential disparities observed by gender, socioeconomic status, race, and ethnicity. Portes suggests that economic disparity and intergenerational mobility among different immigrant groups is associated with the contexts of reception encountered by different immigrant minorities in America. He states with respect to Mexican immigrants: “Mexicans, for example, are regularly persecuted as potentially illegal aliens and are subject to much external discrimination as “takers” of American jobs and “bearers of an inferior culture”. This negative reception inevitably affects the outlook of immigrants, reducing their expectations of what is possible to achieve in their new country, and consequently, their aspirations for their children. Again, this is not a social capital argument, but one grounded on broad structural forces in the society and the polity.”14
I suggest that, in our zeal to be all-inclusive and democratic at least in word, but not always in practice, we have moved towards the concept of “all” rather than targeting and defining vulnerability. Although I embrace an inclusive approach, there is no contradiction between insuring the well being of all citizens, while addressing the basic rights of less economically advantaged citizens. If the United States does not acknowledge the economic and health care rights of our new immigrant citizens, the historically under-represented and most economically disadvantaged groups in the United States, our new focus on social inequality, inequities, and disparities will yield limited or no progress in achieving our Healthy People 2010 objectives.15
STRATEGIES FOR CHANGE Recently, I have had the opportunity, through my own research and course development on the Politics of Women’s Health Care, to review historical and 356
WOMEN’S HEALTH ISSUES VOL. 11, NO. 4 JULY/AUGUST 2001
current policy recommendations on racial and ethnic health over the last three decades. I concluded that many solid and innovative suggestions for change, both in the distant and recent past, have been proposed. Therefore, the question is no longer what do we need to do, but how do we politically institutionalize policies that will de facto increase access and improve quality of care for women of color in the United States? Although some may find this question provocative, for others it is purely humanitarian. Both presenters have provided creative and responsive solutions with which I concur. These include recommendations such as economic security for women, and the institutionalization of link workers, health advocates, or lay workers (promotoras) as part of the U.S. health care system. More specifically coordinated, effective change, not patchwork approaches by government (Federal and state) agencies, must be instituted. Current investments in health, if made with a guiding set of principles to serve all people, with increased resources for those who are most disadvantaged economically, can significantly reduce disparities. High-income communities require less resource investments than low-income and rural communities. We must target defined needs based on specific criteria of economic and social need.
IMPROVING THE HEALTH AND SOCIAL WELLBEING OF WOMEN OF COLOR First and foremost, we need economic and educational equity for women by providing a living minimum wage and quality education system. Tragically, among subgroups of Hispanic/Latinos, over 60% of boys and girls drop out of high school and over 70% of Latinos are not enrolled in college preparatory classes.16 In other words, there is a need to embrace a more comprehensive public health approach that improves and promotes nonmedical systems that strongly influence health. The provision of universal health coverage for all women and their families is essential to promote the health of women of color. Historically, a two-class system with public and private insurers has existed. Why not formalize and universalize it? For example, institutionalize a family health insurance program at 300% of poverty level for all who cannot afford insurance in spite of full-time employment status. We need to develop mechanisms for monitoring and enforcement of state compliance with existing Federal rules and regulations in health service delivery. These include new guidance for limited English language proficiency, public charge, and DHHS cultural competency guidelines. State freedom to implement, if they choose, programs for low-income groups continues to perpetuate national inequities with the most recent example being limited enrollment of poor children in Child Health Insurance Programs in states like Texas and Florida.17 We need to invest in community health resources and develop adequate infrastructures of services and surveillance data systems to monitor our progress as a nation, with standardized socioeconomic and racial and ethnic identifiers. Community-based neighborhood health centers, school-based health and mental health clinics, and public health clinics in communities all would greatly decrease financial and nonfinancial barriers to preventive and primary health care services. It seems that the costs alone of emergency room usage annually by those without health insurance could cover the costs of a strong community health infrastructure of responsive services. The efforts to date have not been adequate. For example, all too often we legislate outreach and yet allocate no or limited dollars to implement the effort. What does this tell us?
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CONCLUSION Overall, women’s health is highly and directly associated with poverty, and indirectly with ethnicity, race, role obligations, the community in which women live, and how they are valued in society. We need to begin to define and focus on those key areas that can decrease disparities, eg, economic security, outreach and education in communities, institutional barriers, racism, and universal health care coverage. Researchers and government agencies in the last decade have already produced volumes and multiple laundry lists of what to do. Such lists immobilize, paralyze, and diffuse the strategies. Yet, there is room for much optimism. Perhaps through the work of this conference and other social equality “thinkers,” we can capture and translate the essence of how measures to reduce racism and increase economic equity can be institutionalized in governmental policies so that new practices will truly make some difference in the health of women of color by improving access and quality of care.
REFERENCES 1. Brown ER, Wyn R, Teleki S. Disparities in health insurance and access to care for residents across US cities. New York: The Commonwealth Fund and the UCLA Center for Health Policy Research; 2000. 2. Brown ER, Ojeda VD, Wyn R, Levan R. Racial and ethnic disparities in access to health insurance and health care. Washington, DC: Henry J. Kaiser Family Foundation and the UCLA Center for Health Policy Research; 2000. 3. Zambrana RE, Scrimshaw S, Dunkel-Schetter C. Prenatal care and medical risk in low-income primiparous Latino and African-American women. Fam Sys Health 1996;14:349 –59. 4. Zambrana RE, Breen N, Fox SA, Gutierrez-Mohamed ML. Use of cancer screening practices by Hispanic women: analyses by subgroup. Prev Med 1999;29:466 – 477. 5. Schulman KA, Berlin JA, Harless W, et al. The effect of race and sex on physician’s recommendations for cardiac catheterization. Engl J Med 1999;340:618 –26. 6. Lillie-Blanton M, Brodie M, Rowland D, Altman D, McIntosh M. Race, ethnicity, and the health care system: public perceptions and experiences. Med Care Res Rev 2000;57:218 –36. 7. National Institutes of Health. Women of color health data book. NIH publication: 98-4247. Washington, DC. Office of Research on Women’s Health; 2000. 8. One voice, one vision: recommendations to the Surgeon General to improve Hispanic/Latino health. Washington, DC: U.S. Surgeon General’s Hispanic/Latino Health Initiative; 1993. 9. Santos R, Seitz P. Benefit coverage of Latino and Latina workers. In: Perez S, ed. Moving up the economic ladder: Latino workers and the nation’s future prosperity. Washington, DC: National Council of La Raza; 2000. 10. Zambrana RE. A research agenda on issues affecting poor and minority women: a model for understanding their health needs. Women & Health 1987; Winter: 137– 60. 11. Perry M, Kannel S, Castillo E. Barriers to health care coverage for Hispanic workers: focus group findings. New York, (NY): The Commonwealth Fund; 2000. 12. Zambrana RE, Carter-Pokras O. Health data issues for Hispanics: implications for public health research. J Health Care for the Poor and Underserved 2001;12:20 –34. 13. Siles M, Perez S. What Latino workers bring to the labor market: how human capital affects employment outcomes. In: Perez S, ed. Moving up the economic ladder: Latino workers and the nation’s future prosperity. Washington, DC: National Council of La Raza; 2000. 14. Portes A. The two meanings of social capital. Sociological Forum 2000;15:1–12. 15. Kass BL, Weinick RM, Monheit AC. Racial and ethnic differences in health. AHCPR publication no. 99-0001. Washington, DC: Agency for Health Care policy and Research; 1999.
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WOMEN’S HEALTH ISSUES VOL. 11, NO. 4 JULY/AUGUST 2001
16. Ginorio A, Huston M. ¡Si, Se Puede! Yes, We can. Latinas in School. Washington, DC: American Association of University Women Educational Fund; January 2001. 17. Zambrana RE, Logie LA. Latino child health: need for inclusion in the US national discourse. Am Public Health 2000;90:1827–34.
Improving Access and Quality for Ethnic Minority Women— Panel Discussion Sylvia Drew Ivie, JD T. H. E. Clinic, Inc., Los Angeles, California
A
lthough we’re talking about the intractable problem of differential treatment of racial and ethnic minorities in both the United States and the United Kingdom, we’re really also talking about systems that work and systems that don’t work for all users. I think we have our finger on some solutions that will improve the situation for those we are focused on here. But if you improve access and quality of health care for the people who get the least of it, you improve it for those throughout the system. No matter what the percentages of minorities are in the two countries, it matters to all of us because we all want the same thing: the best quality health care and the greatest self-sufficiency for women. I’m one of those women in the United States who’s been making a fuss for a long time, and I want to talk about some of the different arenas in which I’ve been trying to make a fuss, all toward the same end of improving access and quality. When things haven’t worked from one vantage point, I’ve moved to another. I’m now in the community clinic world and the community clinic movement and, as you will hear, I think it is an excellent forum for the issues in which I’m interested. I started out as a traditional civil rights attorney, doing civil rights litigation in a variety of areas, such as education and housing, but there was little advocacy among civil rights attorneys in the health arena. I said, “This is so wrong. We have segregation in the United States, racial segregation in health care delivery, and it ought to be addressed with traditional civil rights tools. Why hasn’t this been done?” I worked on expanding access with local civil rights attorneys in the South. In the state of Mississippi, for example, we found private physicians who segregated patients by race in separate waiting rooms. They had a white waiting room and a colored waiting room, often differently appointed in terms of lighting, magazines, and furniture. We said, “This is clearly illegal—we’ve got to go to court and get this enjoined.” We filed the lawsuit and got ready for the trial, and guess what? None of the black patients would testify. It was more important to them to have access to their physicians than it was to eliminate the segregated waiting rooms. Those patients knew what they needed most, and that was health care. Racial equity would have to wait. That has been a recurring dilemma in our work. We went after hospitals, which were running away from inner cities when the populations became too poor or too non-white. The hospitals simply
© 2001 by the Jacobs Institute of Women’s Health Published by Elsevier Science Inc. 1049-3867/01/$20.00 PII S1049-3867(01)00108-6
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Improving Access and Quality for Ethnic Minority Women— Panel Discussion Intersections of Institutional Racism, Socioeconomic Status, Language, and Culture on Women’s Health Ruth E. Zambrana, PhD Department of Women’s Studies University of Maryland College Park, Maryland
INTRODUCTION As I reviewed the two prepared papers, I was intellectually struck by both the tone and depth of understanding reflected and articulated by Drs. Gaston and Bahl’s comments regarding key factors that differently influence the health status of women of color, both in the United States and the United Kingdom. My comments focus on three areas: institutionalized forms of racism, culture and language, and strategies for change. These areas, in my view, are the most intellectually and personally challenging, as we seek to expand our understanding of the health of women of color.
INSTITUTIONAL FORMS OF RACISM Institutional forms of racism as evidenced by lower quality of care for poor women and women of color have been adequately documented in the last 354
WOMEN’S HEALTH ISSUES VOL. 11, NO. 4 JULY/AUGUST 2001
© 2001 by the Jacobs Institute of Women’s Health Published by Elsevier Science Inc. 1049-3867/01/$20.00 PII S1049-3867(01)00109-8
10 years.1–3 Investigators have attempted to measure both obvious and subtler institutional forms of racism that extend on a continuum from the change in attitude of a receptionist when a women of color walks up to a desk, to a physician making a clinical decision not to order a mammogram for a Hispanic woman,4 or other clinically important procedures for an African American woman.5 Unfortunately, although we know that varying forms of racism exist in our health care system and are detrimental to poor people and people of color, in the United States, we tend to shy away from the language that defines the illness of racism.6 Utilizing current mortality and morbidity indicators as our yardstick,7 evidence suggests that institutionalized forms of racism are linked to both access and quality of care for all people of color, but are particularly detrimental to African American and some Latino subgroups. The central question is— how do we decrease or eliminate racial and ethnic disparities among women of color if we hesitate to speak it? Define it? Measure it?
CULTURE AND LANGUAGE Another current and paramount issue that emerges concerns the unqualified attribution of the variables of culture and language as major predictors of health outcome for the Hispanic/Latino population, without acknowledging or taking into account the dynamic and powerful intersection of poverty or low socioeconomic status (SES) with the culture, language, literacy, education level, and political climate of a host country. Culture and language issues have become more salient in the last 10 years with the influx of many immigrant groups. However, the importance of sociocultural factors in relation to health outcome have long been advocated as important, especially with regard to African Americans, and historically under-represented Mexican-origin and Puerto Rican subgroups, both in the United States and on the island of Puerto Rico.8 Although both presenters acknowledge the importance of socioeconomic status as a major barrier to health care access and quality, its significance and the import of the hierarchical mechanisms through which poverty influences all aspects of quality of life and health outcome were not amply discussed. In examining the factors that influence the lives of poor women of color, we need to advance our thinking and understanding that basic rights to access and quality of care are not available to most poor and working-class women. For example, many poor women do not have employment-linked health benefits and/or the money to pay for insurance.9 If they are married or in a partnership, their partners may often not have employment-linked payments or may be unable to afford the cost of family health insurance. Thus, access issues require structural remediation and increased responsiveness to women by providers, if racial and ethnic disparities are to be reduced over the next decade.10 Women with less education have been found to be more intimidated by physician authority, and less likely to ask questions. Studies have shown that physicians are less likely to recommend screening tests and other referrals to women of color in general,4,5 and to poor women in particular. In my work and other empirical work reviewed, there appears to be a merging consensus that, although culture and language are important, we need to elevate the primacy of SES as a marker of education and literacy level that more strongly influences health of low-income Hispanic/Latino women than do culture and even language.4 Low socioeconomic status is closely associated with less access to and knowledge about favorable health care practices, more trusting or less trusting attitudes toward health care providers, less skills to successfully
© 2001 by the Jacobs Institute of Women’s Health Published by Elsevier Science Inc. 1049-3867/01/$20.00
PANEL 3
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navigate the health care system, and less ability to afford the costs of the health care system. Not surprisingly, several studies have found that when access is available and education level is high, language is not a major predictor of outcome.11 In general, higher education level, associated with English-language proficiency, higher literacy levels, and employment-linked benefits is a stronger predictor of access, use of health care services and outcome than culture or language. For Latinas, these characteristics vary substantially by subgroup and must be acknowledged and measured.12 My observations and experience suggest that it is easier for us as a nation to talk about culture and language than to talk about socioeconomic status, literacy, poverty, and inequity. These concepts challenge our basic value system of equality for all. However, to address disparities and inequities, there is a need to identify and target policies for all racial and ethnic groups who remain at economic and social disadvantage, but especially for women of Hispanic/Latino subgroup origin. The Latinas, who constitute the poorest group of minority women, are most at risk of being disproportionately burdened by language and cultural factors. Poverty, as it intersects with these factors, can exacerbate health disparities. Notably, language and culture are central to the Latino experience, whether they are U.S. born or foreign born. Overall, 67% of all Latinos are U.S. born or naturalized citizens and 87% of Latino children are U.S. born or naturalized citizens. Close to three-quarters (74%) report speaking English well. Although the more recent the immigration, the less likely a person is to speak English, not all immigrants have experienced the same type and level of barriers as Latino immigrants.13 In a recent article, The Two Meanings of Social Capital,14 the author provides an additional context in which to understand differential disparities observed by gender, socioeconomic status, race, and ethnicity. Portes suggests that economic disparity and intergenerational mobility among different immigrant groups is associated with the contexts of reception encountered by different immigrant minorities in America. He states with respect to Mexican immigrants: “Mexicans, for example, are regularly persecuted as potentially illegal aliens and are subject to much external discrimination as “takers” of American jobs and “bearers of an inferior culture”. This negative reception inevitably affects the outlook of immigrants, reducing their expectations of what is possible to achieve in their new country, and consequently, their aspirations for their children. Again, this is not a social capital argument, but one grounded on broad structural forces in the society and the polity.”14
I suggest that, in our zeal to be all-inclusive and democratic at least in word, but not always in practice, we have moved towards the concept of “all” rather than targeting and defining vulnerability. Although I embrace an inclusive approach, there is no contradiction between insuring the well being of all citizens, while addressing the basic rights of less economically advantaged citizens. If the United States does not acknowledge the economic and health care rights of our new immigrant citizens, the historically under-represented and most economically disadvantaged groups in the United States, our new focus on social inequality, inequities, and disparities will yield limited or no progress in achieving our Healthy People 2010 objectives.15
STRATEGIES FOR CHANGE Recently, I have had the opportunity, through my own research and course development on the Politics of Women’s Health Care, to review historical and 356
WOMEN’S HEALTH ISSUES VOL. 11, NO. 4 JULY/AUGUST 2001
current policy recommendations on racial and ethnic health over the last three decades. I concluded that many solid and innovative suggestions for change, both in the distant and recent past, have been proposed. Therefore, the question is no longer what do we need to do, but how do we politically institutionalize policies that will de facto increase access and improve quality of care for women of color in the United States? Although some may find this question provocative, for others it is purely humanitarian. Both presenters have provided creative and responsive solutions with which I concur. These include recommendations such as economic security for women, and the institutionalization of link workers, health advocates, or lay workers (promotoras) as part of the U.S. health care system. More specifically coordinated, effective change, not patchwork approaches by government (Federal and state) agencies, must be instituted. Current investments in health, if made with a guiding set of principles to serve all people, with increased resources for those who are most disadvantaged economically, can significantly reduce disparities. High-income communities require less resource investments than low-income and rural communities. We must target defined needs based on specific criteria of economic and social need.
IMPROVING THE HEALTH AND SOCIAL WELLBEING OF WOMEN OF COLOR First and foremost, we need economic and educational equity for women by providing a living minimum wage and quality education system. Tragically, among subgroups of Hispanic/Latinos, over 60% of boys and girls drop out of high school and over 70% of Latinos are not enrolled in college preparatory classes.16 In other words, there is a need to embrace a more comprehensive public health approach that improves and promotes nonmedical systems that strongly influence health. The provision of universal health coverage for all women and their families is essential to promote the health of women of color. Historically, a two-class system with public and private insurers has existed. Why not formalize and universalize it? For example, institutionalize a family health insurance program at 300% of poverty level for all who cannot afford insurance in spite of full-time employment status. We need to develop mechanisms for monitoring and enforcement of state compliance with existing Federal rules and regulations in health service delivery. These include new guidance for limited English language proficiency, public charge, and DHHS cultural competency guidelines. State freedom to implement, if they choose, programs for low-income groups continues to perpetuate national inequities with the most recent example being limited enrollment of poor children in Child Health Insurance Programs in states like Texas and Florida.17 We need to invest in community health resources and develop adequate infrastructures of services and surveillance data systems to monitor our progress as a nation, with standardized socioeconomic and racial and ethnic identifiers. Community-based neighborhood health centers, school-based health and mental health clinics, and public health clinics in communities all would greatly decrease financial and nonfinancial barriers to preventive and primary health care services. It seems that the costs alone of emergency room usage annually by those without health insurance could cover the costs of a strong community health infrastructure of responsive services. The efforts to date have not been adequate. For example, all too often we legislate outreach and yet allocate no or limited dollars to implement the effort. What does this tell us?
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CONCLUSION Overall, women’s health is highly and directly associated with poverty, and indirectly with ethnicity, race, role obligations, the community in which women live, and how they are valued in society. We need to begin to define and focus on those key areas that can decrease disparities, eg, economic security, outreach and education in communities, institutional barriers, racism, and universal health care coverage. Researchers and government agencies in the last decade have already produced volumes and multiple laundry lists of what to do. Such lists immobilize, paralyze, and diffuse the strategies. Yet, there is room for much optimism. Perhaps through the work of this conference and other social equality “thinkers,” we can capture and translate the essence of how measures to reduce racism and increase economic equity can be institutionalized in governmental policies so that new practices will truly make some difference in the health of women of color by improving access and quality of care.
REFERENCES 1. Brown ER, Wyn R, Teleki S. Disparities in health insurance and access to care for residents across US cities. New York: The Commonwealth Fund and the UCLA Center for Health Policy Research; 2000. 2. Brown ER, Ojeda VD, Wyn R, Levan R. Racial and ethnic disparities in access to health insurance and health care. Washington, DC: Henry J. Kaiser Family Foundation and the UCLA Center for Health Policy Research; 2000. 3. Zambrana RE, Scrimshaw S, Dunkel-Schetter C. Prenatal care and medical risk in low-income primiparous Latino and African-American women. Fam Sys Health 1996;14:349 –59. 4. Zambrana RE, Breen N, Fox SA, Gutierrez-Mohamed ML. Use of cancer screening practices by Hispanic women: analyses by subgroup. Prev Med 1999;29:466 – 477. 5. Schulman KA, Berlin JA, Harless W, et al. The effect of race and sex on physician’s recommendations for cardiac catheterization. Engl J Med 1999;340:618 –26. 6. Lillie-Blanton M, Brodie M, Rowland D, Altman D, McIntosh M. Race, ethnicity, and the health care system: public perceptions and experiences. Med Care Res Rev 2000;57:218 –36. 7. National Institutes of Health. Women of color health data book. NIH publication: 98-4247. Washington, DC. Office of Research on Women’s Health; 2000. 8. One voice, one vision: recommendations to the Surgeon General to improve Hispanic/Latino health. Washington, DC: U.S. Surgeon General’s Hispanic/Latino Health Initiative; 1993. 9. Santos R, Seitz P. Benefit coverage of Latino and Latina workers. In: Perez S, ed. Moving up the economic ladder: Latino workers and the nation’s future prosperity. Washington, DC: National Council of La Raza; 2000. 10. Zambrana RE. A research agenda on issues affecting poor and minority women: a model for understanding their health needs. Women & Health 1987; Winter: 137– 60. 11. Perry M, Kannel S, Castillo E. Barriers to health care coverage for Hispanic workers: focus group findings. New York, (NY): The Commonwealth Fund; 2000. 12. Zambrana RE, Carter-Pokras O. Health data issues for Hispanics: implications for public health research. J Health Care for the Poor and Underserved 2001;12:20 –34. 13. Siles M, Perez S. What Latino workers bring to the labor market: how human capital affects employment outcomes. In: Perez S, ed. Moving up the economic ladder: Latino workers and the nation’s future prosperity. Washington, DC: National Council of La Raza; 2000. 14. Portes A. The two meanings of social capital. Sociological Forum 2000;15:1–12. 15. Kass BL, Weinick RM, Monheit AC. Racial and ethnic differences in health. AHCPR publication no. 99-0001. Washington, DC: Agency for Health Care policy and Research; 1999.
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16. Ginorio A, Huston M. ¡Si, Se Puede! Yes, We can. Latinas in School. Washington, DC: American Association of University Women Educational Fund; January 2001. 17. Zambrana RE, Logie LA. Latino child health: need for inclusion in the US national discourse. Am Public Health 2000;90:1827–34.
Improving Access and Quality for Ethnic Minority Women— Panel Discussion Sylvia Drew Ivie, JD T. H. E. Clinic, Inc., Los Angeles, California
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lthough we’re talking about the intractable problem of differential treatment of racial and ethnic minorities in both the United States and the United Kingdom, we’re really also talking about systems that work and systems that don’t work for all users. I think we have our finger on some solutions that will improve the situation for those we are focused on here. But if you improve access and quality of health care for the people who get the least of it, you improve it for those throughout the system. No matter what the percentages of minorities are in the two countries, it matters to all of us because we all want the same thing: the best quality health care and the greatest self-sufficiency for women. I’m one of those women in the United States who’s been making a fuss for a long time, and I want to talk about some of the different arenas in which I’ve been trying to make a fuss, all toward the same end of improving access and quality. When things haven’t worked from one vantage point, I’ve moved to another. I’m now in the community clinic world and the community clinic movement and, as you will hear, I think it is an excellent forum for the issues in which I’m interested. I started out as a traditional civil rights attorney, doing civil rights litigation in a variety of areas, such as education and housing, but there was little advocacy among civil rights attorneys in the health arena. I said, “This is so wrong. We have segregation in the United States, racial segregation in health care delivery, and it ought to be addressed with traditional civil rights tools. Why hasn’t this been done?” I worked on expanding access with local civil rights attorneys in the South. In the state of Mississippi, for example, we found private physicians who segregated patients by race in separate waiting rooms. They had a white waiting room and a colored waiting room, often differently appointed in terms of lighting, magazines, and furniture. We said, “This is clearly illegal—we’ve got to go to court and get this enjoined.” We filed the lawsuit and got ready for the trial, and guess what? None of the black patients would testify. It was more important to them to have access to their physicians than it was to eliminate the segregated waiting rooms. Those patients knew what they needed most, and that was health care. Racial equity would have to wait. That has been a recurring dilemma in our work. We went after hospitals, which were running away from inner cities when the populations became too poor or too non-white. The hospitals simply
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