Demystifying Medicine One Month at a Time

Black & White

black & white

Imagine if I told you that because of the color of your skin, you wouldn’t be allowed access to certain health care services.

Pretty outrageous, right?

After all, discrimination based on skin color or ethnicity is beyond the pale in 21st century America.

What if the color of your skin made you four times more likely to suffer a life-threatening illness?

You might think it unfair, but you’d recall that certain disease states affect different groups of people at varying rates.

When we control for access to care, these differences in health outcomes are known to researchers and advocates as health care disparities.

One of the places I encounter disparate health outcomes most starkly is in the dialysis unit.

Dialysis is blood filtration for people whose kidneys have stopped working. It’s been around since the early1960s, but became mainstream therapy in 1973 when Congress expanded Medicare to include all persons with End Stage Renal Disease (ESRD).

With that generous entitlement, no one with chronic kidney failure dies from it in the United States.

As you might imagine, since the government pretty much automatically covers everyone in this category, a massive economy has sprung up to cater to this market. From the Wall Street Journal’s (6/11/09):

Dialysis treatment costs Medicare almost $72,000 per patient per year; total outlays for patients in kidney failure were $23 billion in 2006, 6.4% of Medicare’s total budget. Overall chronic kidney disease and its complications account for over $49 billion, or about 25%, of all annual Medicare expenditures.

Dialysis also is big business. The vast majority of dialysis centers are for-profit, and DaVita Inc. the nation’s largest provider with 1,400 centers, ranks No. 433 on the 2009 Fortune 500 list with reported 2008 revenues of $5.7 billion and profits of $374.2 million.

I live and work on the South Side of Chicago.

In nearly a decade working at GlassHospital, I can count the number of white people I’ve met in the dialysis unit on one hand. In fact, I can count him on one finger.

Pick a day and come visit our unit (you’ll first have to get permission, of course): Weekday, weekend, first shift or second; doesn’t matter. Every face you’ll see in that unit is black.

After all this time, and in spite of the fact that our government pays for all of this care, I can understand why African-Americans might be mistrustful and even somewhat paranoid about forces conspiring against them in their quests for life, liberty, happiness, and implicitly, health.

I’ve long thought that the unit would make extraordinary fodder for a documentary film by the likes of Fred Wiseman or D A Pennebaker. In that cinema verite style, I could easily imagine viewers having difficulty grasping why it is that outcomes for blacks are so much poorer, even as we’ve improved access to care and desegregated our facilities.

I would line up to see such a film.

We’re collectively so used to the fact that the vast preponderance of dialysis patients are African-American that we don’t even question it. We rationalize away the stark contrast:

Blacks have higher rates of ____________ .

  • diabetes
  • high blood pressure
  • chronic kidney disease

We live in an area of ____________ .

  • lower socioeconomic status
  • urban poverty
  • low educational attainment
  • higher crime

One last item: Because of “national trends,” GlassHospital recently reached an agreement to sell its own outpatient dialysis units. The buyer: DaVita.


  1. The 50 Best Health Blogs

    So, why the disparity? Are African-Americans the only ones who get kidney disease? As a white obese male with type 2 diabetes and hypertension, am I safe from kidney disease?

    Jim Purdy

    • glasshospital

      The simple answer: No one knows. African-Americans have higher rates of diabetes and hypertension, so it follows that they have more kidney disease, an end result of those two conditions.

      As to why they have more diabetes and hypertension, we simply don’t know. Take your pick of factors (or blend them in varying proportions): Genetics. Diet. Increased social stress. Historical disenfranchisement.

      Alas, you’re not safe from kidney disease unless you and your medical advisors are doing the best that you can to “control” the underlying risk factor conditions. But it’s entirely possible that your “white” genetics may confer some “protective” advantage. The science to know this simply isn’t there. Epidemiological associations are not proof of causation, though we often take that mental shortcut.


  2. Tammy

    Greetings, I enjoy your blog. This is a cool site and I wanted to post a note to let you know, good job! Thanks Tammy

    • glasshospital

      Well, Tammy, er, should I say Louis…thanks so much for your very sincere flattery. If you like the blog so much, why not include subscriptions to it with all of the handbags that you’re shilling? They’re no doubt “authentic,” just like your spam bot comment.

  3. Allison

    Louis Gates was on the very scientific program, Oprah, and he advanced a theory that the slaves who survived the middle passage across the oceans did so because they had an increased ability to retain fluid since they were being treated so badly. While that trait helped them then, they in effect selected for hypertension once they reached the new world. While is seems internally consistent, do you think there’s any truth to it? I’ve always wondered about that.

  4. Sunetra

    “Grace” at the end of life from Tedmed is a must watch.
    Here is a link to it.
    You may have to cut and paste the link to watch it.

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