Health Disparities in the Healthcare of African American Males Diagnosed with Parkinson's Disease and Schizophrenia

In the United States, research findings consistently indicate that health disparities in the healthcare of African American males exist in terms of diagnoses of Parkinson’s disease and schizophrenia. Given the prominent position of the United States in influencing global healthcare policies and, thereby, health outcomes for millions of people, the importance and relevance of such findings are heightened. Even further, in light of the quest for the achievement of the Global Millennium Goals, it is literally incumbent upon healthcare experts and policymakers in the United States and other developed nations to examine the health disparities in the healthcare of African American males with Parkinson’s disease and schizophrenia. Doing so can serve as a strategically appropriate starting point for developing improved healthcare policy formats for the United States and the world.

Basic Research Questions

In light of the health disparities in the healthcare of African American males with Parkinson’s disease and schizophrenia, the current study is based on two fundamental research questions. Question one reads as follows: How can the health disparities in the healthcare of African American males diagnosed with Parkinson's disease and/or Schizophrenia be explained? Question two reads as follows: How do the findings of question one relate to global health?

Initial Response

As a matter of providing initial (i.e., hypothetical) responses to the basic research questions, based on the history of institutionalized ethnic and racial bias and discrimination in the United States, it is likely that the subsequent biosocial analysis will reveal endemic characteristics of the healthcare system that, at a minimum, contribute to health disparities in the healthcare of African American males. The depth and scope of the endemic “racialized” characteristics are likely to be both significant and expressive of identifiable historical trends and sources. As for question two, findings are likely to relate to global health according to salient political and social factors. Foremost, the United States is one of the most powerful and influential nations on the planet. Even further, the United States is a world leader, in many respects, in advancing healthcare policies and practices. As such, the hypothesized “endemic biases” in the healthcare system in the United States are extended to the world as seemingly acceptable (i.e., normalized), yet in actuality, they represent a misaligned way of providing healthcare and doing business.

Study Rationale/Methodology

The current study provides a biosocial analysis in relation to health disparities in healthcare for African American males diagnosed with Parkinson’s disease and/or schizophrenia. Emphasis is also provided with respect to how the answers to the basic research questions related to global health. The general biosocial theory itself posits that mental illnesses and conditions like schizophrenia and Parkinson’s disease have a biological (i.e., genetic) component that is triggered, in effect, by environmental factors, or stimuli. In other words, the biosocial theory is based on the assumption that diseases and/or health conditions are the result of the interaction of biological and social forces. In relation to the basic research question of the current study, focus and attention are, therefore, given to the social forces related to the healthcare context and how such forces might interplay and/or contribute to the health disparities in the healthcare of African American males diagnosed with Parkinson's disease and/or schizophrenia. Ultimately, findings are discussed in terms of how they relate, most significantly and relevantly, to the global health context.

Study Preview

The current study is organized into four major sections. Section I provides a background discussion. Section II presents a review of critical literature as related to the basic research questions of the current study. Section III presents a discussion and interpretation of the literature review results, along with commentary concerning the implications of findings. The current study concludes with a brief summary of findings, a statement of limitations, and recommendations for researchers and policymakers.

Definition of Key Terms

Healthcare disparities. As defined by the Health Resources and Services Administration, health disparities (also known as healthcare inequalities) refer to "population-specific differences in the presence of disease, health outcomes, or access to health care” (NewsMedical, 2013).

Parkinson’s disease. Parkinson's disease is a degenerative disease resulting from the loss of dopamine-producing brain cells, resulting in symptoms like tremors in the arms, jaw, legs and face; and impaired movement, balance, and coordination due to stiffness in limbs and trunk (Johns Hopkins Medicine, n.d.).

Schizophrenia. Schizophrenia is a mental illness that usually affects people from late adolescence to early adulthood, although it can strike at any time in life with variable presenting symptoms, sometimes, including delusions, hallucinations, and other odd personal and social behaviors (Johns Hopkins Medicine, n.d.).

Section I: Background Discussion

This section of the current study provides a background discussion from the vantage of biosocial theory. Specifically, analysis relates to the health disparities in the healthcare of African American males diagnosed with Parkinson's disease and/or Schizophrenia. Findings indicate that Parkinson’s disease in the African American male population is under-diagnosed while schizophrenia is over-diagnosed.

A Matter of Under-Diagnosis (Parkinson’s) and Over-Diagnosis (Schizophrenia)

Health disparities are a well-established fact in minority populations in the United States. In fact, when compared to whites, minority groups, including African American men, have apparently, and inexplicably, higher and/or lower diagnosis rates of many diseases, including, but not limited to Parkinson's disease and schizophrenia (NewsMedical, 2013; Anderson, 2011, p. 10). The emerging consensus among researchers and policymakers is that African American men seem to be the subjects of both under-diagnosis and over-diagnosis, depending on the disease or disorder of concern. In the case of Parkinson's disease, Dahodwala et al. (2009) believe, for instance, that African American men are not properly or adequately diagnosed, in many cases. In other words, there is a gross under-diagnosis of African American men with Parkinson's disease. Similarly, yet conversely, when it comes to diagnoses of schizophrenia in African American men, researchers suggest that the tendency is on the other side of the proverbial coin – specifically, over-diagnosis (Anderson, 2011, p. 10).

It would appear that healthcare professionals often characterize presenting problems and behaviors such as stress, depression, anxiety, and so forth as disorientation, delusion, and other symptoms that are commonly characteristic of schizophrenia. Perhaps most problematically, the tendency to over-diagnose African American men - that is, wrongly attribute symptoms and behaviors to schizophrenia - has a long and dubious history dating back decades, and even a century or more. During the Civil Rights Movement of the 1950 and 1960s, for example, ethnic and racial bias convened in such a way as to suppress African American men, wrongly, in the supposed name of science. As researchers note, in fact, the behaviors of vibrant and zealous African men (specifically, black civil rights supporters) were improperly construed and characterized as socially “embarrassing and worrisome” such that the behaviors of African American patients “were conflated with the so-called “schizophrenia” of civil rights protests” (Anderson, 2011, p. 10). What is more, the legacy of such ethnically and racially biased/prejudice treatment of African American men continues to this day as many male members of the African American community are disproportionately diagnosed with schizophrenia. The same researchers point out, for instance, that “attribution of violence or aggression to Blacks seeking mental health services often represents a form of bias associated with racial stereotyping, especially related to black males - such that they are diagnosed wrongly as schizophrenic (Anderson, 2011, p. 9). By implication, the above facts broaden and complicate the research and inquiry such that the biosocial explanation must take into consideration a potentially broad scope of social and historical variables.

As a matter of adding some quantitative aspects to the analysis, the following U.S. census data paints a fairly clear picture. In the United States:

42,163,000 persons are Black and of African American descent of which 19,057,000 are male (U.S. census, 2010). African American males make up 45% of the African American population, and yet when compared to all women, white men and all other ethnic groups in the United States, African American men are diagnosed with schizophrenia to a disproportionate degree in inpatient settings (Anderson, 2011, p. 10).

Interpreted in terms of a simplified ratio, African American males are nearly twice as likely to be diagnosed with schizophrenia as any other population segment in the United States. This fact, of course, raises important questions about the potential interplay between biological factors and social factors that may contribute to and/or cause the health disparities in healthcare for African American males.

Section II: Review of Critical Literature

This section of the current study provides a review of critical literature as it relates to the health disparities in the healthcare of African American males diagnosed with Parkinson's disease and/or schizophrenia. As subsequent analysis suggests, some researchers contend that health disparities in the healthcare of African American males diagnosed with Parkinson's disease and/or schizophrenia are a matter of the interplay between biological and social factors. Still, others highlight the social factors, most notably, in terms of the institutionalized bias and errors of the American Psychological Association and the misleading guidelines of the various versions of the Diagnostic and Statistical Manual of Mental Disorders.

The disparity in Parkinson’s disease for African American Men

In a recent study, Dahodwala et al. (2009) investigated the incidence of Parkinson’s disease in relation to possible contributing/causal factors across multiple dimensions, including, race and ethnicity, demographic factors, geographical location, and healthcare. The researchers predicated their study on the basis of noted health and healthcare disparities across ethnic and racial lines, including African American males. Perhaps most problematically, the researchers found that African-Americans, most often males, are "half as likely to be diagnosed with [Parkinson’s disease] as whites" (Dahodwala, et al., 2009). In attempting to explain this health and healthcare disparity for African American men, the researchers emphasized that demographic factors and access to healthcare service are not the primary drivers. The researchers, instead, found that the interplay between biological differences and other factors such as education or aging beliefs, most likely, represent the crux of the matter (Dahodwala, et al., 2009). Although the researchers were unable to identify the specific biological factors that may be part of the equation, their findings provide validation for the claim that the health disparities in the healthcare of African American males diagnosed with Parkinson's disease and/or schizophrenia are, quite evidently, a function of biosocial considerations.

The American Psychological Association and Diagnostic Statistical Manual of Mental Disorders

In attempting to explain the longstanding tendency towards over-diagnosis of schizophrenia for African American males, researchers in a recent study considered the potential contributing role of the American Psychological Association (APA) and the organization’s Diagnostic and Statistical Manual of Mental Disorders (DSM). The Diagnostic and Statistical Manual of Mental Disorders is effectively a guidebook for clinicians describing the presenting symptoms and characteristics (i.e., criteria) of mental disorders like schizophrenia. Over the past four decades, some four (updated) versions of the Diagnostic and Statistical Manual of Mental Disorders have been published - specifically, DSM I through DSM IV-TR. Most critically, and as a matter of relevance to the basic research questions of the current study, some researchers have begun raising serious questions and concerns about the validity and reliability of the various versions of the Diagnostic and Statistical Manual of Mental Disorders (Anderson, 2011, p 10). Validity refers to whether or not the manual accurately measures what it claims to measure - schizophrenia, for example. Reliability refers to the all-important scientific qualification of repeatability. In other words, if the Diagnostic and Statistical Manual of Mental Disorders is truly useful, it measures what it claims to measure and it does so consistently on a case by case basis, without exception. In both respects (i.e., validity and reliability), researchers have found that problems exist with this classification system such that psychiatrists, in many documented cases, we're unable to agree on which persons were mentally ill, as well as, what type of illness the patients actually manifested (Anderson, 2011, pp 8-9). In sum, although the distribution of the schizophrenia is observed to be only slightly more likely for males in the general population in the United States, African American males are far more likely to be diagnosed with schizophrenia when presenting themselves for clinical diagnosis and treatment (Anderson, 2011, p. 10). Although biological factors can explain, at least, part of the disparity, researchers generally agree that a strictly biological explanation exceeds reasonable and probabilistic boundaries.

By implication, the above findings suggest that diagnoses of African American men who, supposedly, have schizophrenia amount to little or nothing more than subjective opinion, and estimations. In fact, the researchers agreed that this "lack of reliability has led to clinician bias in making diagnoses [which]...raises the possibility that similar validity and reliability issues also may be contributing factors in the misdiagnosis of African American males with schizophrenia” (Anderson, 2011, pp. 8-9). Thus, not only do these findings reveal and expose the unscientific nature of the diagnosis process but, even more problematically, it virtually negates the validity and reliability of the diagnosis process entirely. With psychologists and clinicians being literally entirely dependent on the Diagnostic and Statistical Manual of Mental Disorders to diagnose and treat mental illness, the findings and claims of these researchers are disturbing and far-reaching with respect to noted health and healthcare inequalities in the global health equation.

Global Health Disparities and the Millennium Development Goals

As a matter of relating scientific findings to global health, the World Health Organization has established the Millennium Development Goals in a broad sweeping effort to address an array of inequalities in the world, including health and healthcare disparities. Specifically, the Millennium Development Goals represent as cohesive “set timebound targets, by which progress in reducing income poverty, hunger, disease, lack of adequate shelter and exclusion — while promoting health, gender equality, education, and environmental sustainability — can be measured” (World Health Organization, 2005, p.7). As a matter of relevance to the basic research questions of the current study, the relationship between healthcare inequities and health disparities is recognized by the United Nations and other supporters of the Millennium Development Goals as constituting a complex global problem and issue. In fact, the driving impetus of the Millennium Development Goals is the acknowledgment that health disparities are increasing in the developing world for diverse social and political reasons, not least of which concerns inequitable access to education and healthcare (NewsMedical, 2013). Such findings convene with the results of other studies that highlight the critical role of education of the citizenry in advancing health equity in America and around the world. Thus, it becomes evident that education may represent the most critical and viable method for addressing the health disparities in the healthcare of African American males diagnosed with Parkinson's disease and/or schizophrenia.

Section III: Discussion and Interpretation of the Literature Review Results and Implications of Findings

This section of the current study presents a discussion and interpretation of the literature review results. Commentary is also provided concerning the implications of findings for health practitioners and policymakers. In sum, the findings of the critical literature review provide a validation of the initial response to the basic research questions. Specifically, a case can be made that African American men tend to be under-diagnosed when it comes to troublesome Parkinson’s disease. Conversely, African American men are over-diagnosed when it comes to the putative mental disorder of schizophrenia. Overall, a convergence of biological and social factors can explain the health disparities in the healthcare of African American males diagnosed with Parkinson's disease and/or schizophrenia. Yet, the onus of responsibility for fixing the problem still falls on the shoulders of healthcare experts and policymakers.

The Need to Improve Healthcare Education for African American Males and Others, Globally

As the previous discussion had indicated, findings of the Dahodwala et al. (2009) investigation offer significant implications in relation to global health. Most notably, the researchers highlighted the biosocial interplay between biological propensities and contextual factors that may contribute to the disparity in diagnosis rates of Parkinson's disease for African American men. In highlighting the educational and perception factors, the researchers effectively heighten the call for fulfillment of Millennium Development Goals. Underscoring the Millennium Development Goals, in other words, is the fundamental recognition that education is the great equalizer in society and the world at large. In this respect, the findings of Dahodwala et al. (2009) suggest that African American men are under-diagnosed with Parkinson's disease because, at least in part, they lack proper educational orientation. By extension, the same holds true for populations in the developing world where access to health education is limited and unequal by comparison to members of developed nations. The point, more exactly, is that the findings of Dahodwala et al. (2009) provide a validation of the specific Millennium Development Goal of providing worldwide equality in health education. By implication for policymakers, healthcare experts and healthcare providers, as well as for the full host of global stakeholders, the Millennium Development Goals should be fully embraced as a platform for addressing health and healthcare disparities. This is especially the case as the subject relates to the primary questions and issues of the current study - again, how to explain the health disparities in the healthcare of African American males diagnosed with Parkinson's disease and/or schizophrenia and, further, how the answer(s) to question one relate to global health. In sum, a picture emerges which suggests that healthcare systems and institutions must take charge of the responsibility of providing health education services to ethnic/racial minority groups, including African American men, who are experiencing the negative health impacts of the biosocial interplay equation.

A Paradigm Shift Appears to be in Order

Findings of the current study have also shown that racial bias and prejudice are deeply endemic to the healthcare system and institutions like the American Psychological Association. In particular, the various incarnations of the Diagnostic and Statistical Manual of Mental Disorders (i.e., DSM I through DSM IV-TR) are infused with implicit ethnic and racial bias as well as critical errors that frequently render the diagnosis process of schizophrenia invalid and unreliable. In the grander scheme, the American Psychological Association with its Diagnostic and Statistical Manual of Mental Disorders holds unmatched influence and sway in the context of global health. In fact, healthcare institutions all over the world utilize and rely on the Diagnostic and Statistical Manual of Mental Disorders as the primary and authoritative source for diagnosing and treating mental disorders like schizophrenia. While one would hope that theorists and practitioners who develop the standards of the Diagnostic and Statistical Manual of Mental Disorders are working to address its evident problems with validity and reliability, developments over the past four decades suggest that, in many ways, the problems are only getting worse. The stoutest critics of the American Psychological Association contend, in so many words, that the Diagnostic and Statistical Manual of Mental Disorders (especially, DSM IV-TR) has become an unwieldy monstrosity of sorts. It gives false and misleading labels (such as schizophrenia) to behavioral presentations that often have little and/or nothing to do with such a mental disorder or disease. Given such deeply endemic problems with the American Psychological Association and it's Diagnostic and Statistical Manual of Mental Disorders, serious questions must be raised with respect to how to properly acknowledge the over-diagnosis of schizophrenia in African American males. And even further, with health and healthcare inequalities continuing to persist in the global health context, healthcare experts and policymakers need to consider better ways to validate and adduce reliable diagnoses of mental disorders like schizophrenia.

Is a veritable paradigm shift in mental healthcare in order? Some might claim that entirely revamping or abandoning the Diagnostic and Statistical Manual of Mental Disorders would be analogous to throwing the baby out with the bathwater. At a minimum, members of the American Psychological Association and policymakers need to step up to the plate and address the validity and reliability problems with the Diagnostic and Statistical Manual of Mental Disorders. Validity and reliability form the very crux of all scientific endeavors. In this respect, it can be disturbingly concluded that the basis of schizophrenic diagnoses for African American men, and the population as a whole, is entirely unscientific. Simply stated, this is just unacceptable in the modern age where science and objectivity are supposed to replace subjectivity, unprofessional bias, and even ethnic and racial prejudice. A paradigm shift is not only warranted, but it is entirely overdue, by decades.

The Salient Problem of Over-Diagnosis of African American Men

With respect to the over-diagnosis of schizophrenia for African American males, the salient problem is that "labeling stigmatizes these individuals, thus diminishing their opportunities in areas such as obtaining work, getting decent housing, and maintaining desirable social relationships" (Anderson, 2011, p. 12). In other words, biological factors may, in fact, be a statistically significant part of the prevalence of schizophrenia amongst African American males (though this remains debatable and subject to further research), yet the salient problem concerns the exacerbating impacts of social stigmatization. Even further, the biosocial formula can devolve into a vicious and self-defeating cycle of sorts such that the biological basis of mental disorders like schizophrenia is manifestly induced. As a matter of concomitant complications, researchers also warn that how African American men perceive themselves and their respective mental or health conditions can result in self-stigmatizing labels that lead to effects like “diminished self-esteem and decreased self-efficacy” (Anderson, 2011, p. 12). As a matter of bringing into light the longstanding historical exercise of using mental health research and making diagnoses like schizophrenia to marginalize African American males who are considered a boisterous threat to the prevailing status quo, this amounts to a classic case of misguided and harmful stereotyping. Most problematically, African American males, whether highly conscious of the fact or not, are often influenced, as a matter of personal identity, by stereotypical societal portrayals and depictions of African Americans. As such, many African American males become reluctant to seek healthcare service because they do not want to be criticized or categorized as weak, vulnerable, mentally ill, or any other negative or pejorative manner (Anderson, 2011, p. 12). The concluding point, in this respect, is that the onus falls upon the shoulders of healthcare professionals and policymakers to put a final end to the stereotyping of African American males as being prone to schizophrenia.

Changing Demographics in the United States and the World

In light of the findings of the current study, the rapidly changing demographics in the United States and the world provide good reason to project into the future. Along these lines, the U.S. Census Bureau reported that slightly more than one-third of the U.S. population “identified themselves as members of racial or ethnic minority groups” in 2010 ((U.S. Department of Health and Human Services, 2013). Yet, by the year 2050, the U.S. Census Bureau is predicting that the ratio of the white citizenry to minority citizenry will be approximately 1:1 – that is, 50/50. Changes in demographic composition do not, of course, alter the ethnic and racial bias formula in the United States. In fact, with the population of minorities, including African American males, growing over the next three decades, the probability of the healthcare disparities becoming even more problematic are cause for concern.

With respect to global health, although the Millennium Development Goals take aim at establishing equitable healthcare policies, services, and outcomes around the world, critics point out that the Millennium Development Goals remain inadequate to “cover all the health issues that matter to poor people and poor countries” (World Health Organization, 2005, p. 3). By implication, findings of the current study should provide the impetus for policymakers to expand the purview and ambitions of the Millennium Development Goals. In other words, with so many shortcomings and problems in the healthcare context of the United States with respect to the health disparities in the healthcare of African American males diagnosed with Parkinson's disease and/or schizophrenia, something needs to be done on the global level to hold the tide back.

Conclusion

In conclusion, the current study has provided a biosocial analysis regarding the health disparities in the healthcare of African American males diagnosed with Parkinson's disease and/or Schizophrenia. As a striking and emergent issue, it has been more than five decades since the momentous rise of the Civil Rights Movement of the 1950 and 1960s. During those tumultuous, yet progressive years, African American men were wrongly characterized and diagnosed as schizophrenic. Schizophrenia, in this respect, was used as a pejorative and marginalizing term to hurt and subjugate African American men who were doing nothing more than fighting for equality and their own dignity. Sadly, the legacy of the civil rights era is still a part of society. It is even deeply rooted in the supposed scientific literature of the American Psychological Association with its invalid and unreliable publication known as the Diagnostic and Statistical Manual of Mental Disorders. As such, the entire global healthcare context is impacted by unscientific standards that, by extension, exacerbate and impede the quest for achieving the Millennium Development Goals. Simply put, this is unacceptable. It is, therefore, incumbent upon healthcare experts and policymakers alike to right the proverbial shift. As fundamentally a matter of political will, such an undertaking will amount to nothing less than a paradigm shift in thought and practice.

Finally, as a matter of acknowledgment of the limitations of the current study, the five literature/data sources limit the analysis in both depth and scope. Additionally, one of the main sources [specifically, Dahodwala et al. (2009)] acknowledges notable limitations in terms of their own data sources – namely, ICD-9 codes associated with PD in Medicaid claims, the accuracy of which remains not entirely known. Also, while Dahodwala et al. (2009) attest to the potential biological contributions in health disparities in the healthcare of African American males diagnosed with Parkinson's disease and/or Schizophrenia, the researchers do not identify the specific biological/genetic factors. Therefore, with respect to recommendations for researchers and policymakers, future investigations and policy formats need to address these two limitations. In the latter respect, correction of the endemic biases of the American Psychological Association and the validity/reliability problems with the Diagnostic Statistics Manual will represent a monumental undertaking, even a paradigm shift of sorts.

References

Anderson, L.B. (2011 August). African American males diagnosed with schizophrenia: A phenomenological study. Richmond, VA: Virginia Commonwealth University.

Dahodwala, N., Siderowf, A., Xie, M., Noll, E., Stern, M. & Mandell, D.S. (2009, June 15). Racial differences in the diagnosis of Parkinson's Disease. DOI: 10.1002/mds.22557

Johns Hopkins Medicine. (n.d.). Health Library. Retrieved from <http://www.hopkinsmedicine.org/healthlibrary/atoz/s/

NewsMedical. (2013). Health Disparities - What are health disparities? Retrieved from <http://www.news-medical.net/health/Health-Disparities-What-are-Health-Disparities.aspx

U.S. Department of Health and Human Services. (2013 May). National healthcare disparities report. Rockville, MD: Agency for Healthcare Research and Quality. Retrieved from <http://www.ahrq.gov/research/findings/nhqrdr/nhdr12/nhdr12_prov.pdf

World Health Organization. (2005). Health and the Millennium Development Goals. Retrieved from <http://www.who.int/hdp/publications/mdg_en.pdf