Ostracism

From BMJ USA 2003;June:292

BMJ USA tends not to publish obituaries, but we do so this month to remember Carlo Urbani, an infectious disease specialist who first recognized severe acute respiratory syndrome (SARS) but died tragically from the disease (BMJ USA p 339).

We are deferring articles about SARS itself, not because the disease is unimportant but because current thinking about its epidemiology, diagnosis, and treatment is shifting too fast for an article to maintain its currency into print.

Meanwhile, it is interesting to watch the sociological dynamics engendered by SARS. A kind of stigma has descended on people who return from China, or even Toronto. They are ostracized not because they are infectious but because of where they have been. Even a visit to a Chinese restaurant in Ohio is considered dangerous (USA Today, May 1, 2003). Certainly, the symptoms of SARS engender ostracism. Not long ago a cough and a fever were the nonspecific hallmarks of the common cold, but now a traveler with such symptoms can expect special treatment from airport officials and avoidant behaviors from seatmates.

There is nothing new about this ostracism. It began in biblical times with the isolation of lepers and has continued throughout history, often saving lives. The instinct to keep distance from the infected gave rise to quarantining and for centuries kept epidemics in check.

But how do we defend modern-day ostracism in the medical care of racial and ethnic minorities? African Americans are up to 77% less likely than white Americans to undergo cardiac catheterization or angiography for similar indications. Physicians who viewed videotapes of simulated patients (actors) presenting with identically scripted complaints were 40% less likely to recommend catheterization if the actor was black. Physicians less readily engage African American patients in participatory decision-making.

The reasons for this are unclear. Clinicians may operate from mistaken assumptions about disease epidemiology or the ability to adhere to treatment among members of racial and ethnic groups. Delivery systems and social policy contribute by creating impediments to insurance coverage and access. Patients themselves may cause disparities, declining care because of competing priorities or cultural mores.

But while researchers and policymakers strive to understand the problem, it is disturbing that so much of the public - and so many physicians - know so little about it. In this issue, Drew Altman and Marsha Lillie-Blanton, the president and vice president of the Kaiser Family Foundation, discuss a campaign by health organizations to place this issue on the radar screen of the medical community (BMJ USA p 300).

What can we, as doctors, do about it? A first step would be to test our assumptions: On what basis do we assume that a patient is at higher or lower risk, wants to be told what to do, is unlikely to understand big words, will miss appointments, or will not take the disease seriously? We may be shocked by the paternalism we see in the mirror.

Articles cited in Editor's Choice are listed below, beginning with their BMJ USA page number

BMJ USA p 339 Carlo Urbani (obituary), http://bmj.com/cgi/content/full/326/7393/825

BMJ USA p 300 Racia/ethnic disparities in medical care (Altman et al), http://bmj.com/cgi/doi/10.1136/bmjusa.03060002