The use of stem cells in medicine is no longer just a potential idea of the future, but a commonplace treatment. Hematopoietic stem cell transplantation (HSCT), first performed in 1968, was performed over 60,000 times in 2006 (Joshua, et al.). It is most often used to benefit patients with cancers of the bone marrow and blood, such as leukemia and lymphoma. The multipotent hematopoietic stem cells (HSCs) in the transplant, which will give rise to blood cells in the patient, are most often derived from bone marrow, umbilical cord blood (UCB), or peripheral blood (Park, Bokyong, et al.). These transplants can be autologous, meaning using the patient’s own cells, or allogeneic, meaning using a donor’s cells. Although the procedure benefits many patients, it is a specialized, expensive, technically complex, and intensive procedure that does include a high risk of mortality. Due to these qualities, it is worth it to study whether a racial disparity exists involving access to HSCT. One study shows that including consideration for other factors, black patients with lymphoma were 34-45% as likely as whites to receive HSCT (Majhail, N S, et al.). The results of such studies clearly point out that African Americans have a lower chance of receiving HSCT due to matching difficulties, social factors, and racism. In order to increase successful care for African Americans, it is important to implement smart policy to increase HSCT ease of access for African American patients.
Biologically, African Americans have a lower chance of being treated using HSCT. Since most HSCTs are allogeneic, it is important to find a close human leukocyte antigen (HLA) match in order to minimize procedure complications such as graft-versus-host-disease. Donors are more likely to be found within the same racial and ethnic group, and currently only 7% of bone marrow donors are black. African Americans as a group have the lowest probability for finding a partial HLA match at .58 compared to .93 for Whites (Majhail, N S, et al.). Besides the low frequency of black donors, African Americans are also at a disadvantage because African Americans have the greatest genetic diversity. This is due to historical migration and the fact that African Americans are generally of mixed race due to slavery in the United States (Achenbach, Joel). This leads to a greater variety in HLA allele combinations, making each combination more unique. In the process of finding a donor, patients are asked their ancestry to make it easier to find a match. The problem with this is that African genetic ancestry is truly found within a range of 20% to 95% black and the rest being mostly European (Hollenbach, Jill A., et al.). This large range of possibilities for HLA haplotypes makes it more difficult to find a match quickly. This may contribute to the failure to find a match in a timely fashion, limiting access to HSCT. Due to the genetic diversity of African Americans, black patients face lower access to HSCT as compared to white patients.
There are several factors linked to race that limit access to HSCT for African Americans. The difficulty of finding donors does not fully explain the disparity in African American hematopoietic stem cell care. HSCT is expensive. Due to this, socioeconomic factors play a role in access to HSCT. African-Americans are on average of a lower socioeconomic status, limiting their ability to afford this treatment. However, socioeconomic status does not fully account for the disparity as HSCT use did not increase as median income increased among blacks ("Racial Disparities Persist in Stem Cell Transplant for Multiple Myeloma"). Health literacy also plays a role because HSCT is a sophisticated procedure. Due to there being a lower level of average formal education among the black population, understanding of the procedure is on average more limited ("Racial Disparities Persist in Stem Cell Transplant for Multiple Myeloma"). A lack of understanding of the procedure may prevent African Americans in pursuing or following through with the transplant. In addition, black patients were more likely not to be employed full-time and were more likely to depend on Medicaid or Social Security Income for health insurance ("Racial Disparities Persist in Stem Cell Transplant for Multiple Myeloma"). Two studies have shown lower use of autologous HSCT among those with Medicaid (Costa, Luciano J., et al.). Difficulty in finding transportation to a transplant center, travel and lodging expenses, as well as organizing time off of work can be a hurdle for both a potential African American donor as well as the patient. Due to these disadvantages, blacks are less likely to receive HSCT treatment.
Even when accounting for economic, geographical, and other factors, black patients are still less likely to receive a high quality of medical care, and thus are less likely to receive HSCT. This is where bias and underlying racism plays a role. Most doctors themselves are not explicitly racist, and are committed to equal treatment among all patients. However, every person has subconscious prejudices, or implicit bias. Although this issue is multi-layered and complicated, racism in the healthcare system as a whole has been well-documented as physicians are affected by their own biases. These implicit biases often display themselves in the form of subtle verbal and nonverbal actions, which cause discomfort in the patient, making them less confident in seeking medical care and communication (Penner, Louis A., et al.). There are a plethora of accounts from patients describing the racism they have experienced in the healthcare setting. One patient explains that, “they treated me like I was trying to play them, like I was just trying to get pain meds out of them. They didn’t try to make any diagnosis or help me at all” (Tello, Monique). Nothing in the patient’s record indicated that she would seek out pain medication. In fact, patients of a minority race were less likely to receive proper pain medication, thus leading to a less pleasant patient experience (10 Health Care). This story, as well as many others, points to the common bias against black patients. Stereotypes may dictate the way that a physician interacts with a patient. Under situations that the physician is stressed to make a decision, experiencing anger or anxiety, or experiencing poor communication with a patient, a physician’s stereotypes may be activated and affect decision outcome. Physicians tend to view black patients as less kind, intelligent, educated, less cooperative, and with less social support than their white counterparts, even when accounting for other relevant factors (10 Health Care). Due to this less pleasant patient experience, the system creates a sense of distrust and negative connotation that may make it less likely for black patients to seek treatments such as HSCT. Negative stereotypes can also have an indirect effect on care by restricting the full exchange of information. Patient and physician bias therefore factor in to the decision to pursue transplantation (Costa, Luciano J., et al.). Due to mostly unconscious racial discrimination, black patients do not feel as comfortable in a clinical setting in general, which leads to a lower quality of patient care, including the access to HSCT.
In order to increase African American access to HSCT, policies should be strategically implemented. Some policies are already in place to increase African American access to HCT. For example, the National Marrow Donor Program already has initiatives in place to increase donor diversity (Barker, Juliet N., et al.). To further increase the frequency of African-American HSC donors, it is important to study where black populations most commonly reside. Donor initiative should be strategically placed in these areas, such as New York City (Barker, Juliet N., et al.). The question then becomes how to encourage HSC donations. The use of UCB as a transplant material is a useful resource because HLA matching is less stringent (Majhail, N S, et al.). This would make a great difference in the ease of matching for black patients. In order to increase the number of available UCB transplants, the number of collection center should be increased to make them more convenient to deliver a baby at. To increase the publication and availability of donating cord blood, doctors and midwives should all receive proper training as to how collect cord blood. Every pregnant woman should be education about UCB donation prenatally so that she can make her decision in time to notify the blood bank. Since it is still preferred to have a more close match, these centers should focus on being placed in minority population areas (Williams, Rosalind). To address racism in the healthcare setting is a more complicated issue. A good first step is to recognize the attitudes that exist and acknowledge the discrimination that occurs. One way to work towards fixing this is to further implement this awareness in medical education. This needs to be further implemented into the curriculum for medical schools. Physicians should be trained to individuate patients, meaning to be able to see patients as individuals rather than purely belonging to a racial group. A focus should be put on patient-centered communication (Penner, Louis A., et al.). Not only should this type of training be emphasized in medical schools, but it should be heavily implemented into other healthcare training schools such as nursing programs and physician assistant programs (Penner, Louis A., et al.). Values affirmation exercises are able to allow patients to communicate more clearly. Black patients who completed a values affirmation worksheet had more positive experiences interacting with a physician (Penner, Louis A., et al.). This improves trust and thus makes it more likely for a black patient to seek proper medical care and receive a HSCT if necessary. A policy of integrating values affirmation exercises into the waiting rooms of clinical offices would likely be beneficial for all patients, not just minorities. Addressing HSCT access in the African American population is complicated, but there are steps that can be taken to help the situation.
Medicine is a rapidly progressing field. One such progression, hematopoietic stem cell transplantation, is now a common treatment for cancers of the bone marrow and blood. This life-saving treatment, however, is not equally accessible to all races. African Americans receive HSCT the least.