Across the country, minority populations face significant disparities in medication use. It's time for that to change.
The tentacles of racial and cultural health care disparities extend their reach deep into the fabric of American culture. The complexities are painfully entrenched throughout American identity: from where a person lives and their cultural identity to one’s complexion and economic standing. Sadly, a patient’s experience accessing and navigating the United States health care system also falls on this list, an unfortunate consequence of inherent bias borne from all too common effects of systemic racism and implicit biases. Although many factors contribute to the substandard experiences marginalized communities face in the health care setting, perhaps no reason bears greater weight than the basis on which the United States health care system was founded.
From health care access to medication use disparities, minority populations often bear the brunt of a system not weighted in their favor. While the problem isn’t new—the CDC published a Health Disparities and Inequalities Report in a 2013 issue of Morbidity and Mortality Weekly Report (MMWR)1—the COVID-19 pandemic threw many of the issues surrounding care equity into sharp relief.
Research throughout the pandemic has shown that some racial and ethnic minority groups are more likely, disproportionately so, to be negatively impacted by COVID-19.2-4 The reason is multifaceted: in some communities, racial and ethnic minorities were more likely to be working essential service jobs, increasing the risk of exposure to SARS-CoV-2. And because of systemic disparities in care access, many of these individuals were already living with conditions predisposed to experience worse COVID-19 outcomes.
Even after treatments like monoclonal antibodies became available, a MMWR report found that of a total of nearly 6 million patients in PCORnet health care systems evaluated, “mean monthly [monoclonal antibody use] among all patients with positive SARS-CoV-2 test results” were lower among patients who were Black, Asian, Hispanic, or non-Hispanic compared with patients who were White.3
Both race and socioeconomic standing play strong roles in dictating a person’s success. A person’s financial background, for example, can be an indicator of their overall health. In fact, personal wealth is so predictive of individual health outcomes and overall health that the scales remain drastically imbalanced and in favor of those with financial security.5
“The US health care system was designed by and set up to care for White people, so of course, it does the best job caring for White people,” said Andrew Schmelz, PharmD, assistant professor of pharmacy practice at Butler University in Indianapolis.
“Because our health care system is structured around businesses and management of payment and profit, how much money someone has directly impacts how healthy they are,” Schmelz told Drug Topics®. “This creates an environment where money, which…is controlled by social factors, plays an outsized role in determining health outcomes.
Historically, the United States health care system has focused on the biologic drivers of health, Schmelz explained. However, emerging data indicate that social determinants—which include access to clean water and healthy foods, the ability to afford medications, and adequate housing, among others—also affect overall health and well-being.
Chronic diseases tend to be more prevalent in Latino and Black communities as opposed to the White population.6 As a result, these communities are predisposed to use more medication. But despite these higher incidences of medication use, less access to medical care and greater financial constraints in these communities mean that many still struggle to achieve optimal rates of medication adherence. In fact, both groups are at least 50% more likely to have poorer adherence rates than the White population.6
A growing body of evidence indicates that Black patients face additional barriers in the form of discrimination and the effects of implicit bias by health care providers. In health care education settings, curriculum on race- and ethnicity-based health inequities can be limited,7,8 and compounded by biases that certain medications—for example, those used to treat pain—may work “better” or worse in patients based on race.9
Language differences can further amplify medication use disparities. Such is the case for members of Latino and Asian communities who have language barriers when receiving care.
“[One] contributing factor to the low incidence of medication use [among] Latino and Asian communities is a lack of health literacy due to language barriers,” Donney John, PharmD, executive director of NOVA ScriptsCentral in Falls Church, Virginia, told Drug Topics®.
Across the spectrum, members of non–English-speaking communities may not feel comfortable asking questions of their health care provider, concerned about appearing as if they are “questioning” or not respecting their provider’s knowledge and training, John explained. But sometimes, medication information is not translated into a language that patients can easily understand, leading to vital information being lost in translation.
John encourages pharmacists and other health care professionals to seek resources other than Google Translate. Although this tool can be beneficial in day-to-day life, instances of inaccurate translation of medication-related information have been noted.10
Misunderstandings and patient engagement hesitancy owing to language barriers are not the only factors leading to disparity and inequality across the health care system. In some communities, individuals may prefer to turn to alternative healing practices, which could result in lower medication use. Once again, cultural idiosyncrasies make the situation more difficult to quantify.
“I would argue that non-Hispanic White [individuals] may also follow these practices and have some more common to their own culture—for example, doing “cleanses” to remove “toxins” from the GI tract,” Schmelz said. “Also, medication use for specific diseases (eg, drugs for opioid use disorder) has been historically stigmatized, and populations with higher incidence of these problems [are] disproportionately affected.”
The brutal murder of George Floyd by police in 2020 ignited widespread discussions around diversity, equity, and inclusion (DE&I), said Schmelz. Although encouraging, DE&I as a field isn’t new, and there is skepticism that this increased attention will result in any meaningful changes in how we train students or how we provide care.
Frank North, PharmD, MPA, president-elect of the National Pharmaceutical Association in Houston, shared some similar concerns regarding how meaningful changes look and whether they are effective.
“DE&I is [a] hot topic we see schools implementing, but is it done so in an effective way?” he asked. “Some institutions are wrapping their minds [around] the need for DE&I and the fact that communities of color have different experiences.”
These efforts are wide ranging. Some include steps to create narratives that change how the health industry discusses drug efficacy and disease prevalence, Schmelz said. Other efforts have involved research11 intothe impact of implicit biases—“attitudes or stereotypes that affect our understanding, actions, and decisions in an unconscious manner”11—on pharmacy education.
Education can help create awareness among providers about their own implicit biases while providing strategies to provide more culturally competent care. However, this isn’t a panacea for medication use disparities. According to John, cultural competence—defined as an ability to understand, appreciate, and interact with individuals from cultures different from one’s own12—requires grace and introspection.
“All patients—regardless of gender or race—want to be provided with care that treats and engages them with respect,” he said. “Understanding the concept of cultural humility will go a long way for people to learn who to improve the health literacy for patients from different backgrounds so that they will be more responsive to medication therapies.
The narrative of cultural competency, while important, has 2 major limitations.13 First, it inadvertently introduces bias and stereotyping by implying that a person can collect information about group of people; and second, it creates the false notion that cultural competence is an area in which a person can become 100% proficient.
A growing body of evidence suggests that cultural competence is on its way to becoming an antiquated concept—perhaps rightfully so. Its origins date back to the ‘60s and ‘70s, an era marked by sociopolitical turbulence.
Cultural humility—a second-generation iteration of cultural competency—first emerged in 1998.13 The term acknowledges the fluidity of culture predomination while recognizing that understanding and honoring one’s culture is a lifelong process that commands reflection and introspection.
Empathy is another critical piece to solving the medication use disparity puzzle, especially when it comes to engaging the patient with practical action points.
“As a pharmacist, I don’t like to take medication myself, so I may not be as adherent to medication regimens if they are too cumbersome,” John admitted. “So, I try to put myself in the patient’s shoes and think [about whether] I could follow through on the recommendation that I am asking them to follow.”