Achieving health equity among demographic groups is a crucial policy aim. Despite this policy focus, substantial gaps in health outcomes between black and white Americans remain, and black men consistently rank lowest on a broad array of health outcomes. A growing body of qualitative literature, as well as anecdotal evidence, suggests that mistrust of healthcare institutions explains some of this inequity. Still, both theoretical and empirical research on the causal role of medical mistrust in health disparities remains thin. We propose to partially fill this gap in the literature using the Tuskegee Study of Untreated Syphilis as a case study. The proposed research will be the first to estimate the impact of the Tuskegee study disclosure in 1972 on the behavior and subsequent health outcomes of black men. Because we observe outcomes and behaviors both before and after the 1972 disclosure, we can quantify the effect in a quasi-experimental context. The timing of the Tuskegee disclosure coincides with the advent of a period of rising mortality inequality for black men relative to their white peers. This divergence, which we date to the mid-1970s, reversed patterns of convergence apparent throughout the 1960s. The role of historic deceptions in the evolution of these disadvantages for black men, along with possible mitigating factors, are understudied but crucially important areas of research that affect disadvantaged populations around the globe. This project has two specific aims: (1) To estimate the impact of the Tuskegee study disclosure on racial disparities in health-seeking behavior (as reflected in care avoidance and/or delay) and in mortality using predictions derived from economic decision theory. To achieve Aim 1, we have developed a theoretical basis for the evolution of medical mistrust and medical service uptake to inform the proposed empirical methodology. In addition, we propose (2) To evaluate whether the effects of the Tuskegee disclosure on health behaviors and outcomes were mitigated by the availability of minority providers, previous experience with the medical system, or socioeconomic status. The proposed study has several advantages. First, documenting the temporal profile of racial health disparities among men is a substantial contribution to a thin literature on health outcomes in the years immediately following the passage of the Civil Rights Act and the implementation of Medicare and Medicaid Acts in the United States. Second, medical mistrust is difficult (and unethical) to randomize in an experimental setting, and the Tuskegee event provides a ?natural experiment? which is race-specific and has a sharp disclosure date, facilitating comparisons of behavior before and after 1972. The timing of the event also allows us to measure longer-run outcomes for those exposed to information about the event. Third, an exploration of effective strategies to reduce the impact of mistrust on health disparities provides policy-relevant lessons that can aid in furthering the aim of health equity today.
Achieving health equity and eliminating health disparities is one of the four overarching goals of Healthy People 2020, although great strides have been made, health disparities between black and white Americans are still profound. The proposed research will provide novel evidence on whether and to what extent mistrust shapes the demand for health care, particularly among minority populations thereby contributing to steep health gradients. Because medical mistrust is difficult (and unethical) to randomize in an experimental setting, we use the Tuskegee syphilis study as a ?natural experiment? and examine it impact on health seeking behavior and outcomes; we explore effective strategies to reduce the impact of mistrust on health disparities provides policy-relevant lessons that can aid in furthering the aim of health equity today.
| Alsan, Marcella; Wanamaker, Marianne (2018) TUSKEGEE AND THE HEALTH OF BLACK MEN. Q J Econ 133:407-455 |
