The first Endocrine Society statement on Health Disparities in Endocrine Disorders was published in 2012.1 The Society highlighted the current state of health disparities and provided recommendations for future research needs in diabetes, gestational diabetes, thyroid disorders, osteoporosis and metabolic bone disease, and vitamin D deficiencies. Specifically, a call was put out for more basic science, clinical, and translational research in non-White populations.
Today, researchers from Johns Hopkins University are digging even deeper. In a statement published in the Journal of Clinical Endocrinology and Metabolism, 2 authors acknowledged challenges that minority populations may face—less access to adequate health insurance and high-quality care, leading to poorer outcomes and health inequity. They pose a larger question: Why does this disparity exist?
In the African American population, numerous historical contributions to health disparities have been identified. Slaves were frequently subjected to medical experimentation, against their will and without anesthesia. Today, biased beliefs persist that Black patients have a higher pain tolerance. In a post-Civil War America, only 2 universities trained Black physicians, leading to a lack of Black professionals trained to care for their own communities.
Throughout the nineteenth and twentieth centuries, discriminatory policies continued to support structural and institutional racism, creating poor social and living conditions later supported by federal redlining policies. While the 1968 Civil Rights Act mitigated some of these issues, these racist policies still have residual effects on Black people across the United States.
National standards guiding health organizations in both promoting and achieving health equity have been established by the U.S. Department of Health and Human Services Office of Minority Health. According to authors, these standards require healthcare organizations to “establish culturally and linguistically appropriate goals, policies, and accountability” in addition to a plan for continuous improvement, as they work towards health equity.
These standards also recommend that organizations collect accurate and reliable demographic data in order to monitor and evaluate disease outcomes based on factors like race, ethnicity, English proficiency, sexual orientation, and gender identity, among other characteristics. In conditions like diabetes especially, this information will allow health providers to provide the assistance that patients need to fully participate in their care.
The collection of accurate demographic data serves the additional purpose of allowing healthcare organizations to identify where, precisely, disparities in disease outcomes exist. From there, healthcare providers and other decision makers can evaluate what interventions can be undertaken to reduce the disparities and promote health equity.
One 2017 study3 found that for HbA1c improvement, effective interventions were tailored to participants culture and level of health literacy, led by community educators rather than physicians, incorporated validated treatment algorithms, and provided both feedback and high intensity interventions over a long period of time. Similarly, interventions that improved glycemic control in minority patients included the involvement of support staff, enhanced follow-up through home visits, telephone, or mail contact, and point-of-care HbA1c evaluation.
A diverse, inclusive workforce is also key in achieving health equity. As of 2018, only 10.5% of endocrinologists and 12.6% of internists in the U.S. identify as being of Black or African American, American Indian or Alaska Native, Hispanic, or Native Hawaiian or other Pacific Islander— the groups that are most underrepresented in American medicine.
“These figures,” the authors wrote, “are startling given the high prevalence of diabetes in these populations…. [T]he two specialties caring for the majority of patients with diabetes lack of a physician workforce reflecting this diverse population.”
On the policy level, addressing both poverty and racism—two social determinants of health —will also help improve health outcomes. As policy changes the healthcare system and physician education about social determinants of health increases, equity in both access to care and care quality will improve.
“Through partnerships with the Government Affairs Office at our local academic institutions and Endocrine Society Advocacy, we can support the development of legislation to address housing and food insecurity, lack of access to physical activity options, and job insecurity so that everyone can attain their highest level of health,” the researchers concluded. “Academic medical centers must harness their intellectual capital and meaningful partnerships to address the largest component of overall health, the social determinants of health.”
1. Golden SH, Brown A, Cauley JA, et al. Health disparities in endocrine disorders: Biological, clinical, and nonclinical factors—an Endocrine Society scientific statement. J Clin Endocrinol Metab. 2012;97(9):E1579-E1639.
2. Golden SH, Joseph JJ, Hill-Briggs FH. Casting a health equity lens on endocrinology and diabetes. Published online January 26, 2021. J Clin Endocrinol Metab. doi: 10.1210/clinem.dgaa938
3. Golden SH, Marthur N, Mathioudakis N, et al. The case for diabetes population health improvement: Evidence-based programming for population outcomes in diabetes. Curr Diab Rep. 2017;17(7):51.