April 25, 2004

Frist Priority: Medical Affirmative Action

Last Priority: Competent Doctors

By Steve Sailer

Senate Majority Leader and surgeon Bill Frist (R-TN) is pushing as his "highest priority" a bill he introduced along with Louisiana Democrat Mary Landrieu called "Closing the Health Care Gap Act of 2004." It's intended to eliminate racial and ethnic disparities in health care. Or maybe in healthiness. It's hard to tell from Frist's explanation what he's thinking. If anything.

For example, in his justification for the bill, he points out:

"The prevalence of AIDS among African Americans is nine times higher than that of whites, and the prevalence of AIDS in Latino populations is four times higher than that of whites."

That's certainly a health disparity, but is it caused by a health care disparity?

Twenty years ago, hemophiliacs were indeed in danger of getting AIDS from bad health care via transfusions of infected blood, but nowadays, almost nobody gets AIDS from health care. They get it from not taking care of their own health, by doing two things their mothers really don't want them to do (sharing needles while injecting drugs and/or allowing themselves to be penetrated by an infected man not wearing a condom). That blacks and Latinos get infected with HIV many times more often than whites (and dozens of times more often than East Asians) has little or nothing to do with any "health care gap," and everything to do with how black and Hispanic individuals behave on average.

Now, it's at least arguable that the Federal government ought to try to persuade black and brown people not to abuse their own health, although those seem like good lessons for all of us. Studying Frist's bill, though, it's clear that most of its impact would be to institutionalize further the pernicious notion that racial or ethnic differences in health are most likely due to discrimination and must be fought by racial preferences. (See Sally Satel's March 1, 2004 Weekly Standard article "Don't Despair over Disparities" for details on the argument over discrimination.) Frist's bill would establish an Office of Minority Health within the Department of Health and Human Services to (among other things) "Increase awareness of disparities among health care providers, health plans, and the public."

And the bill would fund programs "to increase diversity of health professionals." Frist tells us, "These programs are critical to help health professions institutions increase the number of underrepresented minority students and faculty to achieve a culturally competent workforce."

But what about "a medically competent workforce?" I almost died in my thirties because when I asked my doctor look at a big lump in my armpit that had been there for a couple of months, he said, "It doesn't feel like a tumor. It's probably just a muscle pull." Fortunately, I fired him and went to a competent doctor, who felt it and hustled me into a CAT scan right away. I had Non-Hodgkin's Lymphoma, Stage 4B. (There is no next stage.)

(I then searched the Internet and found a clinical trial just opening up of a revolutionary monoclonal antibody called Rituximab. Seven years later, it's a hugely successful drug and I'm very much alive and feeling fine.)

What "increasing diversity" means in the real world is that more competent white and Asian applicants to medical school are rejected in favor of less competent black and Hispanic ones. Why does Bill Frist want to inflict less competent doctors on America? Ask him. I'd love to find out.

It's not as if African-American youths have never had anyone tell them to become a doctor. How many times have you seen a black kid in the ghetto being interviewed on TV and he says, "I want to be a doctor or a lawyer when I grow up." Doctor or lawyers—that's what African-Americans tell their children to be. They don't seem to suggest more practical ambitions such as, "Be a purchasing agent for a big corporation. Vendors will give you lots of free NBA and NFL tickets."

Medical school affirmative action is frequently justified on the grounds that doctors who got in on a racial quota are more likely to wind up working in a minority neighborhood. This is always presented as a heroic sacrifice by the quota doctor, as if Cedars-Sinai in Beverly Hills was dying to get him, but he felt such a strong sense of racial solidarity that he instead chose to work at a VD clinic in Compton. A more realistic (if cynical) explanation for why people who wouldn't have gotten into medical school except for belonging to a privileged minority tend to end up at low paying jobs in bad neighborhoods is because they tend to be relatively lousy doctors. Under any system, crummy parts of town will get stuck with crummier doctors on the whole, but quotas mean that the worst doctors are worse than they have to be.

Still, it's no doubt true that blacks and Hispanics receive worse health care than whites and Asians. Why? Largely for the same reason that they make less money. Getting good health care, especially an accurate diagnosis, is complicated work.

For example, a couple of years ago I came down with an intermittent cough so violent that I would sometimes vomit. Random ralphing puts a crimp in one's social life, I found. After a couple of weeks, I went to a doctor. He didn't have a clue. After a three more weeks of torture, my wife came up with a diagnosis: whooping cough. We Googled it and found the illness fit my symptoms exactly. We went back to my doctor with a sheaf of printouts. He scoffed, claiming that no one ever got whooping cough anymore. (Like many people, he seemed to confuse subliminally the still-very-much-with-us whooping cough with the nearly extinct whooping crane.) But we showed him our documentation, so he reluctantly prescribed the antibiotic we wanted. Within 48 hours, I was cured. I owe it 100% to my wife's smarts and dedication.

The hidden problem behind much of poor health and poor health care was outlined in a remarkable March 14th Dallas Morning News article by Karen Patterson called "Exploring the health gap between rich and poor: Researcher suggests intelligence may explain disparity among groups:"

"In two recent scientific papers, researcher Linda Gottfredson [co-director of the Delaware-Johns Hopkins Project for the Study of Intelligence and Society] proposes that rather than poverty causing ill health (and, generally, lower IQ scores) among lower social classes, intelligence disparities may underlie class differences both in wealth and health. …

Patterson went on:

"Dr. Gottfredson argues that taking care of one's health can be viewed as an increasingly complex, lifelong job. Much of this job is shifting from doctor to patient, as medicine's focus shifts from treatment of acute ills to prevention and management of chronic ones. Even if all patients had the same medical care and resources, some would exploit them better than others to guard their health, she says. 'The reason is that people differ in their ability to learn information, to understand the information that's provided to them, and their inclination and ability to go seek out information, understand what's relevant,' she says."

In a paper written with Ian Deary of the University of Edinburgh, Gottfredson looked at a remarkable database. On June 1, 1932, all the eleven-year-olds in Scotland took an IQ test. When their health was assessed decades later, according to Patterson:

"Follow-up data revealed that intelligence at about age 11 could predict differences in adult sickness and death rates even after scientists accounted for socioeconomic status… Higher childhood intelligence was linked to higher survival chances until about age 76. And intelligence didn't seem to influence which of the subjects started smoking. But those with higher scores were more likely to later quit."

Part of the problem is that doctors, who are well-above average in intelligence on average, have a hard time realizing just how weak their patients' problem-solving skills often are, especially among the old and the ill. Patterson noted:

"Dr. Gottfredson cites a 1995 finding that more than a quarter of some 2,600 patients struggled to understand when their next appointment was scheduled. Forty-two percent didn't grasp directions for taking medicine on an empty stomach…  'Bright people tend to greatly overestimate the abilities of the average person,' Dr. Gottfredson says, and 'the person who is below average is going to hide that they don't understand.'"

Gottfredson has some suggestions for helping:

"'Perhaps a simple intelligence screening test could be given to patients, so doctors could tailor their explanations and instructions. Or medical students could receive more thorough training in patient communication Health aides, druggists and others could also make sure patients grasp what they need to know. 'I think the way to make a difference is ... to see the opportunities for infusing, you might say, mental assistance,' Dr. Gottfredson says."

The military does a good job training recruits in the 90-100 IQ range (it doesn't accept many below that level) in part because it assigns high IQ officers to find what U. of Chicago law professor Richard Epstein calls "simple rules for a complex world." Football coaches are good at this too, but in much of the rest of American society, the intelligent often create needless complexity, partly because it's easy, partly because their less intelligent clients need to rely on them to decipher it for them. There's something deeply immoral about that.

Gottfredson also has a proposal for patients:

"Viewing health care as a job could help, says Dr. Gottfredson, because lessons from the workplace could be applied. 'This is where I think you have leverage. You're not going to change people's intelligence, but you can change tasks.'"

So, the best way for the federal government to improve health is to creatively figure out how smart people can help those whose brains aren't running on all eight cylinders to look out better for their own health.

Generally, the dread letters "IQ" are not allowed to be discussed in public, but health offers a politically innocuous venue. The wrath of the politically correct is unlikely to fall on somebody just for suggesting that some of the elderly and ill aren't as good at problem solving as they used to be, and that therefore our medical care system needs to adapt better to that unfortunate reality.

Disastrously, though, Senator Frist is focusing urgent emphasis on race and ethnicity. That makes the IQ explanation largely unusable, because some censorious busybody will sniff out that the logical implication of mentioning that many health problems are caused by lower IQ is that a big reason that blacks and Hispanics have more health problems is because they have lower IQs on average.

And that can't possibly be mentioned in polite society. Even if lots of patients must die to keep the truth covered up.