[Congressional Record Volume 141, Number 123 (Thursday, July 27, 1995)]
[Extensions of Remarks]
[Pages E1526-E1527]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]



[[Page E 1526]]


  A MINOR REDUCTION IN THE NUMBER OF CARDIOLOGISTS WILL MEAN A LARGE 
    REDUCTION IN AN ALREADY INSUFFICIENT NUMBER OF AFRICAN-AMERICAN 
                             CARDIOLOGISTS

                                 ______


                           HON. KWEISI MFUME

                              of maryland

                    in the house of representatives

                        Wednesday, July 26, 1995
  Mr. MFUME. Mr. Speaker, most authorities now agree that the current 
number of cardiologists practicing in the United States is more than 
sufficient to meet the anticipated demand for cardiovascular care.\1\ 
However, even with this surplus, concerns persist with regard to the 
distribution of cardiologist over various practices roles (e.g., 
pediatric, clinical, interventional, research, etc.) and patient 
populations (e.g. identified by race, ethnicity, proximity to an urban 
center, etc.)., The harm in maldistribution over practice roles in 
easier to identify than the harm in maldistribution over patient 
populations. Furthermore, the maldistribution itself is easier to 
quantify and remedy in the former case than in the latter. Yet, just as 
we appreciate the need to correct the imbalance of cardiologist \2\, we 
must also recognize that the dearth of doctors in poor communities 
seriously affect the health status of African-Americans.
     Footnotes at the end of article.
---------------------------------------------------------------------------
  In Adarand v. Pena, 1995 U.S. Lexis 4037 (1995), the Supreme Court's 
most recent affirmative action ruling released on June 13, 1995, was a 
significant setback on the general issue of affirmative action, but it 
does not pose an insurmountable hurdle for federal programs such as 
those that would increase the number of Black cardiologists. Adarand 
held that affirmative action programs must meet a standard of ``strict 
scrutiny'' and must be ``narrowly tailored.'' The Supreme Court was 
careful not to suggest that affirmative action programs were 
unconstitutional. While heightened standard requires more of a direct 
relationship between the programs administered and previous racial 
discrimination, the lack of Black cardiologists in the Medical 
profession and its subsequent impact on African-Americans communities 
should be sufficient to meet this burden.
  African-Americans and the communities in which they live are 
typically underserved and the need for cardiovascular care greatly 
exceeds their proportion of the United States population. In fact, 
African-Americans have one of the highest rates of mortality from 
cardiovascular disease in the world. Significant intraracial, 
interracial, and ethnic differences in the incidence and management of 
cardiovascular disease have been repeatedly demonstrated. For instance, 
the prevalence of coronary heart disease, while similar for both 
African-American male and white men, is greater in African-American 
women than in white women.\3\ The prevalence, and severity of 
hypertension is substantially greater in Africa-Americans than in 
whites. Yet the causes of these disparities have never been 
sufficiently explained.
  Because cardiovascular disease is the most common cause of death in 
African-Americans, it is a pressing issue in the African-American 
community. Although there has recently been a steep nationwide decline 
in mortality from coronary heart disease and stroke, little of that 
much heralded improvement has trickled down to the African-American 
community. In fact, stroke mortality has increased in African-American 
men.
  While there is a strong public consensus that social status and 
income are corrected with improved health and longevity, Dr. John 
Thomas of Meharry Medical College found that the mortality and 
morbidity of African-American physicians mimic that of high school 
dropouts. He reports a wide death gap between African-American and 
white physicians with
 white physicians living almost 10 years longer than African-American 
physicians.

  Where African-Americans have benefitted from the decline in 
mortality, they have not done so in sufficient numbers to halt the 
widening of the gap between African-Americans and whites. If the 
mortality rate in African-Americans from all causes were reduced to 
that of white Americans, 60,000 fewer African Americans would die each 
year \4\. Cardiovascular disease accounts for more than 40 percent of 
the excess deaths in African American women and more than 20 percent of 
the excess deaths in African American men.\5\
  Despite their disproportionate demand for health services, African 
Americans as a group do not receive sufficient cardiovascular care. 
They make fewer office visits for coronary disease than their white 
counterparts and are less likely to be seen by cardiovascular disease 
specialists \6\. Even when cost or insurance coverage is not an issue, 
African Americans receive fewer interventions that White Americans.
  The cardiovascular care that African Americans receive is 
insufficient for many reasons. African Americans communities tend to be 
poorer and underserved with regard to all services, medical services 
included. Perhaps, more importantly, many of the medical professionals 
who serve in such communities lack a meaningful understanding of the 
cultural factors which may distinguish their patients from the 
mainstream. Insight into a patient's routines, traditions, family 
structure, diet, stresses, and other factors which are largely 
culturally determined are key to developing a treatment plan that works 
for that patient. African-American patients may be wary of the medical 
establishment that has not responded appropriately to their needs. 
There are still physicians who have separate rooms for Africa American 
and White patients. This wariness may make them less likely to make 
routine nonemergency visits to the doctor, to follow a treatment plan, 
or to follow up with a specialist. This situation is of special concern 
in the field of cardiology because so much of cardiovascular health 
depends on early detection of ``silent'' signs, such as hypertension. 
Furthermore, patients with cardiovascular diseases are often called 
upon to endure the unpleasant or even painful side effects of 
medication or give up activities they enjoy in order to combat a health 
problem that is not causing them pain. So much of cardiovascular 
disease and its treatment seems counterintuitive that it has been the 
subject of a great deal of misinformation and home remedy. Crisis care 
of cardiovascular diseases is not a good option.
  African American cardiologists are the best hope for allaying many of 
these insufficiencies. The key reason is that many more African 
American doctors than other doctors locate their practices in socio-
economically underserved areas \7\. A second reason which should not be 
overlooked is that African American cardiologists are more likely to 
have insight into the cultural differences in treating African 
Americans and are best situated to develop rapport with them. They are 
better able to instill confidence in their patients and thereby ensure 
their patients' compliance with treatment plans.
  An increase in the number of African American cardiologists will 
increase their positive effect. African American patients have shown 
that they will; go out of their way to receive care at the hands of 
African American practitioners, but all too often they do not have the 
choice. In most American cities with an African American population of 
at least 5%, patients do not have the option of receiving their care 
from an African American cardiologist. Consequently, 80% of the 
cardiovascular care that African Americans receive is provided by 
practitioners who are not African American.
  There are very few African American cardiologists. African Americans 
make up 11.2% of the U.S. population, but less than 3% of the U.S. 
physicians. There are
 approximately 15,000 board-certified cardiologists in the United 
States,\8\ of whom less than 300 are African-American. A mere 1.5% of 
cardiologists in training are African-American.

  The number of African American subspecialists is low for many of the 
same reasons that the number of Black professionals is generally low. 
The main reason is economics. As a group, African Americans have fewer 
financial resources than whites and so are less likely to have the 
luxury of pursuing subspeciality training. Their communities' need for 
their skills and their families' need for their earning power may push 
them into the work force earlier. By that reasoning, the proposed 
extension of training requirements from three to four years will weed 
out African American physicians even further from subspeciality 
training and Board certification.
  Often white males benefit from the assumption that they are honest, 
competent, and possessed of a work ethic where their African American 
counterparts do not. Although this imbalance is largely due to an 
unwillingness on the part of Americans and the media to recognize these 
attributes where they are displayed by African Americans, there is also 
unmistakably a crisis in the African American community. Whatever the 
reason, unacceptable levels of violence, crime, drug abuse, welfare 
dependence, and other social ills pervade a segment of the African 
American community. The odor of bad apples tempt a segment of the 
population to throw up their hands at the whole barrel. African 
American professionals have paid dearly for this state of affairs. 
Every member of the Association of Black Cardiologists has a story to 
tell about the perseverance it took to overcome these presumptions.
  A related reason for the low number of African American 
subspecialists is the self-perpetrating nature of prestige and 
connections. Only those who have the intangible benefits are in a 
position to acquire them. African Americans are less likely to have the 
benefit of role models and mentors to help them develop as black 
professionals and unlock career opportunities for them. The 
administrators who make the admissions and hiring decisions along a 
cardiologist's path to success remain 

[[Page E 1527]]
mostly white, which is perhaps not as important as the fact that they 
also remain mostly beholden to the status quo. For many of them, there 
is a network of relatives, family friends, colleagues, fraternity 
brothers, and club members to be considered for these choice slots 
before an opening is made available to a minority. Furthermore, even 
where the old boy network is not abused, many administrators consider 
it beyond the scope of their task to consider the populations their 
beneficiaries will serve. They have little reason to seek out or invest 
in a candidate who is not like them.
  Furthermore, there are forces at work to make it more difficult to 
establish a health care practice. Cutbacks in government health funding 
and reimbursement levels threaten to destroy vital primary and 
speciality practices. Moreover, new emphasis on ``managed'' care is 
expected to reduce the demand for specialists in cardiology.\9\ As 
African Americans generally have practices with less than three 
partners, they are at greater risk under the new efficiency paradigm in 
health care delivery. In addition, African Americans, having only 
lately come into the subspecialties in significant numbers, may be more 
vulnerable to these forces than more established practices.
  The number of cardiologists in this country has been determined by 
factors that have little to do with patient demands, primarily the 
labor needs of the hospital community. Unlike some areas of the private 
sector, opportunities for training and a career in a medical specialty 
are kept artificially finite, as the bands on the electromagnetic 
spectrum. Medical schools, residency programs, fellowships, hospitals, 
and medical boards are ordained to dole out ever-scarcer privileges.
  The medical community must be free to compensate for the artificial 
scarcity. In order to ensure that underserved communities get the 
health care they need, we must bolster and protect the existing 
practices of primary and specialty care physicians in underserved 
communities and ensure that the number of African-American physicians 
continues to grow. We must protect and expand hard-won positions set 
aside for the medical training and career development of minorities, 
especially in the subspecialties.
  We must be uncompromising in our condemnation in our condemnation of 
the violent, anti-social, anti-intellectual, or irresponsible forces in 
the African-American community while supporting the institutions that 
are working. Just as medicine has moved from crisis management toward 
prevention as the best approach to public health, we must put our 
resources into halting the cycles of poverty, crime, and isolation. The 
best law enforcement policy has always been a sense of community. The 
best welfare program has always been education. We must target 
promising African-American students early, motivate them to pursue 
medicine, and give them financial support and mentoring at every stage 
of the career path.
  We must call on training and hiring institutions to take an active 
role in shaping the health care community in two key ways: First, to 
commit to compensating for the artificial barriers to African-
Americans' success; second, to commit to ``casting a wider net'' in 
seeking out talented African-American. Over 50 percent of cardiology 
training programs have never admitted an African-American. If the 
United States to benefit from inclusion, it must do more than fight 
discrimination. It must lean against the exclusionary tilt that exists 
in training program. We must come to see no minority participation in 
cardiology division as a sign that such an exclusionary tilt is at work 
and call on those institutions to pursue their commitments with more 
vigor.
  African-American physicians are not supplicants at a rich man's door. 
Contrary to the beliefs of some, the choice is not between a highly 
qualified White candidate and a barely qualified African-American 
candidate. There is an ample cadre of talented African-American 
physicians yearning to be cardiologists.
  While there is no shortage of cardiologists in general, the 
disproportionate number of Black cardiologists will only be enhanced if 
programs which increase the number of minority cardiologists are 
abolished. If the Adarand case is used as fuel to feed fires of 
negative legislative action, it will re-enforce the stereotypes America 
needs to eliminate in order to move forward as a nation. A precise 
reading of Adarand verifies that under certain circumstances, the use 
of race or ethnicity as a decisional factor can be legally sustained. 
The extremely high mortality and morbidity rates of African-American 
more than establish the need for increased Black Cardiologists. 
Affirmative action programs can assist in reaching this goal.
                               footnotes

     \1\ 19th Bethesda Conference: Trends in the practice of 
     cardiology: Implications for manpower. J. Am. Coll. Cardiol. 
     1988; 12(3):822-836
     \2\ Last year the 25th Bethesda Conference of the American 
     College of Cardiology pronounced that cardiac surgeons are in 
     adequate supply, and that there is even an overabundance of 
     invasive cardiologists. The college recommended that the 
     number of trainees in adult cardiology be decreased. But in 
     the same report, the ACC found that more pediatric 
     cardiologists are needed if the underserved are to be brought 
     into the mainstream of cardiac care. 25th Bethesda 
     Conference: Future personnel needs for cardiovascular health 
     care. J. Am. Coll. Cardiol. 1944;24(2):;275-328.
     \3\ Report of the Secretary's Task Force on Black and 
     Minority Health. Margaret Heckler (secretary): U.S. Dept. of 
     Health and Human Services, 1985.
     \4\ Ibid.
     \5\ Ibid.
     \6\ Ibid.
     \7\ Council on Graduate Medical Education Third Report. 
     Improving access to health care through physician work force 
     reform; directions for the 21st century. Washington, DC: U.S. 
     Dept. Health and Human Services, October 1992.
     \8\ In 1992, there were 13,611 board-certified cardiologists 
     in the United States.
     \9\ 25th Bethesda Conference: Future personnel needs for 
     cardiovascular health care. J. Am. Coll. Cardiol. 1994; 24 
     (2): 275-38.
                     KOREAN WAR VETERANS' MEMORIAL

                                 ______


                           HON. SAM GEJDENSON

                             of connecticut

                    in the house of representatives

                        Thursday, July 27, 1995
  Mr. GEJDENSON. Mr. Speaker, I rise today in honor of the dedication 
of the Korean War Veterans' Memorial. The Korean war lasted 3 years, 
but our memories of those men and women who gave their lives and 
livelihoods while fighting in Korea will last forever. The Korean War 
Veterans' Memorial aptly provides this recognition. This tribute to the 
brave men and women who fought in Korea more than 40 years ago is long 
overdue, and I am pleased that after nearly a decade of work, the 
memorial will finally be unveiled today.
  The memorial is also a good opportunity to improve citizen awareness 
of the sacrifices made, and the service given, by our veterans in 
defense of our Constitution and the liberties it guarantees. All too 
often, we take our freedoms for granted. These precious freedoms were 
defended by those who sacrificed their lives in times of war. They are 
preserved by those who exercise their rights in defense of peace.
  Today, there are more living American veterans than at any point in 
history. They are among the reasons that the United States is the 
mightiest, wealthiest, most secure Nation on the Earth today. They are 
the reason the United States has been, and will continue to be, the 
bastion of support and solace for those in a world still searching for 
freedom and human rights.
  As a Member of Congress, I am pleased to be in a position to honor 
our veterans. They willingly went to war to defend our freedoms and the 
American dream we all strive to achieve. In this time of restricted 
budgets and divisive rhetoric, we must pause to recall the commitment 
given to use by those veterans and we must honor the commitments we 
have made to them.


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