Stepping Up to the Plate

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Will Recruiting Black HIV Experts Help the Diverse Healthcare Needs of African Americans Who Are Being Left Behind?
by Larry Buhl

At the end of many days, David J. Malenbrache, MD, is wiped out, not just by the workload but also by the number of people in his community who are black, affected with HIV, and have nowhere else to turn. Dr. Malenbranche, an assistant professor at the Division of General Medicine at Emory University’s School of Medicine in Atlanta, also supervises medical providers-in-training at the Urgent Care Center at Grady Memorial Hospital in downtown Atlanta and treats patients at the Ponce Infectious Disease Center, a local AIDS clinic.

“There are few black doctors, with a small percentage of those who are specializing in HIV and an even smaller percentage who specialize in treating men who have sex with men [MSM] and a tiny percentage of those providers who are also gay,” he tells A&U. “It’s a cross to bear to be a black gay physician and see it disproportionately affecting your own population.”

According to the Black AIDS Institute, which put out a report called Left Behind, approximately 500,000 African Americans live with HIV/AIDS, and almost half of the more than 56,000 new HIV infections each year in the U.S. occur among blacks, yet barely two percent of the nation’s medical doctors are black, with just a handful specializing in HIV treatment.

And while major metropolitan areas do have some HIV-specializing doctors and nurses who have the cultural competency to serve these populations, patients of color in small and rural communities, often in the Southeast U.S., are usually out of luck. South Carolina has the eighth-highest HIV rate in the country and now has zero state funding for the AIDS Drug Assistance Program (ADAP), according to the South Carolina HIV/AIDS Council, referring to that state legislature’s decision to eliminate its ADAP budget. “Across the South, black folks have almost zero access to care,” the Council states.

The search for Black HIV specialists
Black physicians and those who treat people of color with HIV say the best black HIV doctors are doing a Herculean task with the resources available to them. But many black doctors who could serve people of color with HIV often don’t have the skills and the cultural competence needed to give the best care.

Goulder Downer, PhD. Photo © by Ron Caesar
“Seventy percent of new HIV cases in the United States come from people of color,” says Goulda Downer, PhD, RD, director and principal investigator for the National Minority AIDS Education and Training Center at Howard University. “Very many of these patients are from a lower socioeconomic strata and their cases are medically complex,” she tells A&U. “They often will come to see a doctor when their disease has advanced. And they often suffer from other problems such as obesity, diabetes, and hepatitis.”

The complexities affecting these patients puts an added strain on already overburdened healthcare providers, Downer tells A&U. “Doctors who serve them have such a high caseload and they don’t have the time to talk with them and be social workers. It’s mentally draining for the doctors, who may not even live in the communities they are seeing.”

Part of the problem in finding black doctors or any doctors willing to work in clinics serving lower income people is the lack of a financial incentive.

“Private doctors are not jumping up and down to attract new patients on Medicaid,” admits Wilbert Jordan, MD, medical director of the OASIS Clinic in Compton, Calif. “They at least want to be reimbursed at the Medicare rate.” But most practices and clinics that serve people of color tend to have a much higher rate of Medicaid patients, he emphasizes.

Dr. Malenbrache agrees. “HIV magnifies an already terrible business model of the American medical system,” he tells A&U. “It’s not patient-driven. It’s a for-profit business. Unlike Canada, where medical school is heavily subsidized by the government, new doctors in the U.S. can face a half a million dollars of debt.”

For black students the financial difficulties often pile up before med school. According to the Journal of Blacks in Higher Education, of those black students who attend college, only forty-three percent obtain their undergraduate degree. The article faults inferior K–12 preparation and an absence of a family college tradition, conditions for the high dropout rates. But family wealth and the availability of financial aid contribute to the dropout problem. According to a study by Nellie Mae, the largest nonprofit provider of federal and private education loan funds in this country, sixty-nine percent of African Americans who enrolled in college but did not finish said that they left college because of high student loan debt as opposed to forty-three percent of white students who cited the same reason.

Overcoming stigma and prejudice
Those few new doctors of color who do make it through the system carrying their debt burden who do want to serve lower income populations with HIV many times have another road block: their own cultural competence.

“The reason so many gay white doctors got involved with HIV in the beginning because it was largely seen as a gay disease,” Dr. Jordan says. “HIV is still a passionate issue with the gay white community but it is not with the black community. We don’t have enough black folks speaking up on behalf of black people with HIV.”

“There is still a stigma about the disease, even among so-called educated people and even among doctors and when HIV is stigmatized by doctors, it is a death sentence for the HIV patients they serve,” Downer tells A&U. And with nearly a quarter of those practicing medicine in the U.S. being trained outside the country, many working in remote areas, there are often additional attitudes standing in the way of good healthcare.

“Some doctors trained in other countries will say to us, ‘in our culture, if a woman has HIV we believe she should be left to die,’ or ‘men having sex with men is a capital offense in my country and they are killed.’ You don’t want doctors treating you if they hold these beliefs.”
And it isn’t just doctors who must understand the realities of HIV without stigma. “When a person comes in to the front door of the office or clinic, the entire staff must be welcoming.”

There are a variety of reasons about why HIV/AIDS disproportionately affects the Black population in the U.S., from a higher poverty rate to the stigmatization of gay sex, to a higher rate of IV drug use (many of these issues are overlapping). Doctors, assistants, nurses, and other professionals need to understand the background issues in order to provide the best care to black HIV patients, Downer says. She adds that there are additional difficulties in caring for those with different language and ethnic and cultural identities, such as blacks from the Caribbean and parts of Africa.

Dr. Downer, who was born in Jamaica but trained in the U.S., says practitioners must better understand the diversity of backgrounds of their black patients. “Professionals need to know what to do if a person who comes from the islands, for example, insists that she got HIV because her grandmother must have done something evil.”

Educating and creating infrastructure
Dr. Downer insists that anyone who is licensed to practice medicine anywhere should have a minimum of six hours of training in HIV. “This should be done by the states. It is a public health as well as a security issue.” For her part, Dr. Downer and her institute have helped provide cultural relevance training to more than 43,000 clinicians and providers over the past ten years.

As part of the National HIV/AIDS Strategy (NHAS) unveiled last July, President Obama made increasing the number of AIDS doctors and health specialists a priority. NHAS states that to properly care for the thousands of HIV-positive Americans who are expected to be introduced into the system, the U.S. must create a pipeline of culturally competent HIV-care providers, including doctors, nurses, physician’s assistants, and other practitioners. The eventual rollout of promised state insurance exchanges, part of the Affordable Health Care Act of 2010, many in the black communities who are underinsured or lack insurance could benefit, experts say. But a big stumbling block, as always, is money. With states cutting back severely on public services, and states slashing ADAP funding, the problems could get worse for many people of color in the near future.

Even with the Administrations’ attention to the issue, it’s still an uphill climb to bring more black doctors into the system, help low income people afford care, and train all types of practitioners in the intricacies of treating the populations they serve and make it financially worth their time to do so. Dr. Downer believes it can be done as long as physicians who are doing a good job are acknowledged and encourage other black physicians to become trained in HIV. She also says the HIV Testing and Awareness Day on July 24, will help spread the word that more black doctors need to step up to the plate.

Larry Buhl is a freelance journalist and screenwriter living in Los Angeles.

February 2011